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■«>■> 5 



PRINCIPLES OF PATHOLOGY 



PRACTICE OF MEDICINE. 



PRINCIPLES 



PATHOLOGY 



PRACTICE OF MEDICINE 



BY 

JOHN MACKINTOSH, M.D., 

LECTURER ON THE PRACTICE OF PHYSIC IN EDINBURGH, &C. &C. &C. 

FOURTH AMERICAN, 

FROM THE LAST LONDON EDITION. 
WITH NOTES AND ADDITIONS, 

BY SAMUEL GEORGE MORTON, M.D., 

I OKMERLY PHYSICIAN TO THE PHILADELPHIA HOSPITAL; AUTHOR OK ILLUSTRATIONS OP 
PULMONARY CONSUMPTION, &C.&C. 



V 



PHILADELPHIA: 
LINDSAY AND BLAK1STON 

1844. 






Entered according to Act of Congress, in the year 1844, by 

LINDSAY & BLAKISTON, 

in the Clerk's Office of the District Court of the United States, for the Eastern 
District of Pennsylvania. 



T. K. & P. G. Collins, Printers. 



TO 

HENRY WARBURTON, Esq., M.P. 

&c. &c. &c. 
THIS WORK IS INSCRIBED, 

AS AN HUMBLE TRIBUTE OF RESPECT AND GRATITUDE 
FOR THE GREAT BOON CONFERRED ON THE 

MEDICAL PROFESSION 

BY THE 

ANATOMY BILL, 

OBTAINED THROUGH HIS INDEFATIGABLE EXERTIONS ; 

AND FOR THE 

IMPARTIALITY, TALENT AND ASSIDUITY WITH WHICH HE, 

AS CHAIRMAN OF THE SELECT COMMITTEE OF THE HOUSE OF COMMONS, 

HAS CONDUCTED THE ARDUOUS INVESTIGATION INTO THE 

STATE OF MEDICAL EDUCATION, 

AND WHICH HAS EXCITED THE ADMIRATION OF 

PERSONS OF ALL PARTIES, 

BY 

THE AUTHOR. 



TO 



SIR JOHN WEBB, K. C. H. 

DIRECTOR-GENERAL OF THE ORDNANCE MEDICAL DEPARTMENT, 

&c. &c. &c. 
Mr Dear Sir, 

In presenting you with two of the preceding editions of this 
work, I can say, with truth, that I was actuated solely by a desire 
of perpetuating a record of my esteem for your public and private 
worth, and of my gratitude for the many acts of kindness received 
from you in the course of more than twenty-five years, during 
which period I have had the pleasure and honour of enjoying your 
friendship. 

It is with no small degree of satisfaction that I take this oppor- 
tunity of again dedicating the Fourth Edition to you, in conjunction 
with Mr. Warburton, believing that it will not be the less acceptable 
on that account. 

I am, 

My Dear Sir, 
Your faithful and obliged Servant, 

JOHN MACKINTOSH. 



PREFACE TO FOURTH EDITION. 



The original object of this work was to provide those gentlemen 
who did the author the honour of attending his lectures, with a Text- 
Book, in the hope that it might be found useful to them in prosecut- 
ing their studies. For some time the sale was confined to his own 
pupils, and the work was entitled " Heads of Lectures" But the 
author was subsequently advised to launch the result of his labours 
before the professional public with the title changed to that of 
'■'Principles of Pathology and Practice of Physic" — "trusting, 
that with all its faults and imperfections, it would be indulgently- 
received as an humble attempt to establish a pathological system of 
medicine." [Preface to First Edition.) 

The success of this work has far surpassed the author's sanguine 
expectations ; three large editions having been disposed of in the 
course of six years. 

In offering a fourth edition to the profession, the author, very 
sensible of the respect due to its members, and of the flattering man- 
ner in which the work has been received, has taken every precaution 
to render it worthy of a continuance of their patronage. It is con- 
siderably enlarged — the import of every paragraph has been well 
considered, many errors have been corrected, and the size of the 
type and the quality of the paper have been materially improved. 
He was so well aware of the imperfections of the work, that he 
courted the remarks of several friends, well qualified by their learn- 
ing, experience and ability, to undertake such a task ; he has availed 
himself of their written and oral criticisms, and endeavoured to turn 
them to the best advantage. The author stands particularly in- 
debted in this respect to Mr. Marshall, deputy inspector-general of 
hospitals, famed for a correct acquaintance with the literary, as well 
as the practical part of medicine — for being an accurate observer, 
an inductive reasoner and an admirable critic. If all his sugges- 
tions have not been adopted, more particularly as to pursuing an 
abstract style of writing, it has not arisen from any want of respect 
for his opinions, but merely because the author entertains rather 
different sentiments. 

The author wishes his work to be regarded merely as a book of 
facts, carefully collected and examined — he lays no claim to be con- 
sidered more wise, learned or original than any other professional 
man in the enjoyment of similar advantages, and who has pursued 
the same patient method of investigating diseases. He has been 
very sparing in the introduction of hypothetical discussions, and 
when he has attempted to explain or establish any point by reason- 
ing, he trusts it will be found for the most part to be strictly inductive. 



x PREFACE. 

Whatever feeling may exist as to the manner in which he lias 
treated the opinions of others, the author knows that his efforts are 
perfectly sincere and well intended. In teaching the principles of a 
profession of such unbounded importance to mankind, he has ever 
felt himself called upon, by the combined influence of reason and 
humanity, to treat professional statements, theories and practices in 
the most unreserved manner. No duty is more incumbent on a me- 
dical writer, on whose labours the lives and happiness of thousands 
may depend. The author is not aware that he has ever been guilty 
of indulging in any expression which he would be afraid to repeat 
in the presence of the persons whose opinions he has impugned? 
neither can he be justly accused of bestowing praise from personal 
friendship, nor of condemning from personal animosity. He will 
never be ashamed or backward to confess an error, and he will 
feel no reluctance to give up every opinion he has formed, however 
long and arduous his investigations may have been, for others which 
may hereafter be proved to be more correct. He has given the best 
proof of the candour which actuates his conduct in the article on 
cholera, in which he has felt himself obliged to repudiate all the 
opinions he entertained, when writing the former editions. 

The author most heartily deplores the morbid sensibility and 
irritability which exist among medical men— no parallel to which 
can be found in the history of any other liberal profession. Few 
medical men can bear to know that the soundness of their opinions 
has been questioned ; they regard any such attempt as a signal of 
deadly personal hatred, and view it in the same light as if their 
moral character were maliciously assailed. On what circumstances 
does this frame of mind depend? The author has always attributed 
it to an overweening conceit, selfishness and pusillanimity. Some 
may object to these statements, however true, being put in print, 
because they may think them calculated to injure the dignity of the 
profession and to produce bad feeling. But the author cannot 
believe the existence of real dignity and good feeling, where there 
is such a deplorable want of high-mindedness and moral courage: — 
besides which, these pages are written exclusively for the profes- 
sional, and not for the public eye. It cannot be denied that practi- 
tioners in medicine stand too low in the scale of public estimation, 
and that "something is rotten in the state of Denmark." But the 
author trusts soon to see an important change in the profession, the 
first steps towards which must be a considerable modification of 
corporation privileges, and a greater degree of care and discrimina- 
tion on the part of those who teach the different branches of medi- 
cine, in exciting industry and zeal among their pupils, and inducing 
them, by precept and example, to regard the profession of medicine 
more as a science, and the blessed means of doing good, than as a 
corrupt jobbing trade. Much substantial good might also be effected 
by examinators for medical diplomas, were they to feel that their 
own personal honour depended more on the high moral and profes- 
sional qualifications of the gentlemen admitted into the profession, 
than on the amount of fees received. 

The facility of granting medical degrees in all the universities of 



PREFACE. xi 

Scotland, has been quite disgraceful. It would not be difficult to 
point out many persons who would be puzzled to conjugate a verb 
or decline a noun in any of the dead or living languages, and who 
could not, if their lives depended on the result, write or even speak 
their mother-tongue correctly, who, nevertheless, have had the credit 
of writing a long and elaborate Latin essay, and have successfully 
gone through a hocus-pocus examination before learned professors! 
This trade of granting degrees in physic on the part of the Univer- 
sity of Edinburgh, attracted the attention of the members of the 
Royal Commission appointed by his majesty to inquire into the 
state of the Universities in Scotland, who were astonished at the 
small increase of students, compared with the large increase of gradu- 
ates during the course of twenty years, from 1806 to 1826. At page 
167 of the Appendix to the Genera] Report, the Commissioners state, 
"that the increase from 1S06 is very great, and cannot be accounted 
for by an increase of medical students; for, in 1S06, the number 
was 764, and in 1S26, only 896, that is, there was an addition of 132 
students, but this bears no kind of proportion to the multiplication 
of degrees from 37 (in 1S06) to 118 (in 1S26)." But with all due 
submission to the honourable commissioners, the result can be easily 
explained. The first principles of natural philosophy, which slum- 
bered in other places, advanced rapidly in the University of Edin- 
burgh after the year 1S06 ; — a strong desire had prevailed to discover 
the philosopher's stone— this, it is well known, failed; but the Edin- 
burgh professors soon arrived at that supreme degree of mental per- 
fection, to find out the value of the precious metals, which they after- 
wards manufactured in a wholesale manner, by converting pieces of 
parchment into gold. It was not every professsor that was considered 
sufficiently skilled in philosophy to entitle him to participate in the 
handsome pecuniary dividend — no ! no ! Here, again, there was a 
monopoly confined to six professors, who would not permit the others 
to share the spoil. But as this transaction may not be credited, the 
author will quote another passage from the same Report: "It does 
appear quite unreasonable, that when there are belonging to the 
university a number of professors, who must be supposed equally 
skilled in medical science, there should be a monopoly of examina- 
tions to a particular part of them, apparently for no other purpose 
than that the persons so favoured may receive the addition to their 
emoluments arising from the fees paid to the examiners" (Page 
167.) 

There is, likewise, a curious circumstance in the history of the 
Scotch universities. It is well known, that of these, St. Andrew's 
and Aberdeen had been in the habit of granting medical degrees 
upon certificates from qualified persons in the profession, without the 
personal appearance of the candidate, and consequently without the 
safeguard to the public of an examination. This was done for ages, 
and no public remonstrance was made from any quarter. The Uni- 
versity of Edinburgh went on with her monopoly and disreputable 
practices, and she quietly allowed the sister institutions to do as they 
pleased. But in the year 1833, the University of St. Andrew's, 
(simultaneously with the Universities of Oxford and Cambridge), 



xii PREFACE. 

remodeled her laws, reduced the graduation fees to the same standard 
as Edinburgh, improved the course of study and appointed compe- 
tent examiners, which satisfied the public that none but well quali- 
fied persons could obtain a degree at that university. Bnt it did not 
satisfy the professors of the University of Edinburgh that it would not 
destroy their monopoly and rob them of their "loaves and fishes." 
It cannot be too extensively known, that the University of Edin- 
burgh allowed a system, injurious to the public and derogatory to 
medical science, to continue for ages without uttering one word of 
complaint; yet no sooner was an excellent system established, a 
system avowedly better than her own, then she commenced a war 
of agitation, by which she intended to shake the very walls of Wind- 
sor Castle, if his majesty would not put an extinguisher upon the 
St. Andrew's examiners. Memorials were drawn up, petitions were 
presented, the highest law authorities were retained ; other universi- 
ties and colleges were enlisted in the unholy cause ; by an intrigue, 
the College of Surgeons of Edinburgh was induced to join hands 
in the crusade, and petition the king in council to do an illegal act. 
But the triumph of justice has been complete. Many persons of con- 
siderable eminence and of high moral worth repaired to St. Andrew's 
in the mean time, and having undergone strict examinations, received 
their degrees. The result has been, that a plan nearly similar to that 
of St. Andrew's has, it is believed, been adopted in London by the 
king and council, who by charter established a central board of ex- 
aminers, to grant medical degrees to all candidates who may be found 
well qualified, whether they have acquired their medical education 
within or without the walls of a university, that is, under professors 
or lecturers. 

Thus, aided by accidental circumstances, has the author, by devis- 
ing and planning the improvements adopted by the University of St. 
Andrew's, succeeded in destroying the most odious monopoly that 
ever disgraced British legislation. The author feels that he is justi- 
fied in applying the term "odious monopoly," to any system that 
retards the progress of that science upon which the health and hap- 
piness of every one depend. 

The author trusts to the wisdom of Parliament for the speedy 
enactment of more liberal and equable laws respecting medical edu- 
cation ; the adoption of a uniform system for all the schools ; and a 
more rational mode of granting degrees in universities. It is to be 
hoped that the new institutions, which must, as a matter of course, 
follow the recently chartered establishment in London for the grant- 
ing of degrees, will be formed upon similar principles. 

Edinburgh. 31 Albany Street. 



PREFACE TO THE FOURTH AMERICAN EDITION. 



The high estimation in which Dr. Mackintosh's Practice of Medi- 
cine is held both in this country and in Europe, is sufficiently attested 
by the fact that it is now published for the eighth time, four editions 
having appeared in England and four in the United States. 

In presenting it again to the medical profession, I have inserted 
various materials which, but for the untimely and lamented death 
of the author, would have been far more ably supplied by his own 
hands; and, in the prosecution of this task, my object has been to 
express myself with brevity, rather than to embarrass the work 
with unnecessary details. All the added parts are enclosed in 
brackets ; and I have been careful to preserve the original text 
entire, excepting a part of the cases illustrative of the treatment of 
intermittent fevers by bleeding in the cold stage: but as the author's 
own judgment led him to omit these cases in his early editions, 
and, as they were finally inserted merely to sustain a controversy 
on a point of practice which has few or no advocates in this country, 
I have regarded them as superfluous, and have therefore omitted 
them. 

The section on the "Physiological Doctrines" has been retained, 
with slight alterations, as originally prepared by my friend Dr. 
Joseph Carson, and published in the former American editions. 
For, although these views and the practice which was based upon 
them are fast becoming obsolete in this country, their popularity is 
of so recent a date as to form an important feature in the medical 
history of our own times, while it still exerts its influence on the 
minds of many practitioners. 

It gives me pleasure to add, that, in the last letter I received from 
Dr. Mackintosh, written a short time previous to his death, he ex- 
pressed his entire approbation of the manner in which I had edited 



xiv PREFACE TO THE FOURTH AMERICAN EDITION. 

his work, and his gratification at the flattering reception it had met 
with by the medical public of this country. 

I much regret that Prof. Chapman's "Lectures on the more im- 
portant Diseases of the Thoracic and Abdominal Viscera," did not 
come to hand until the corresponding parts of the present volume 
were already prepared for the press; or I should more frequently 
have availed myself of a work which embraces forty years' expe- 
rience of a gentleman who, by common consent, stands at the head 
of his profession in the United States. 

S. G. M. 

Philadelphia, August 26, 1844. 



CONTENTS. 



PART T. — GENERAL HISTORY 
OF INFLAMMATION AND FE- 
VER—WITH THE PATHOLO- 
GY AND TREATMENT OF IN- 
DIVIDUAL FEVERS. 

Chap. I. — Doctrines, Causes, Phe- 
nomena and Effects of In- 

n.A.MMATOX. 

General Doctrines which have 
prevailed respecting Inflam- 
mation, 

Causes of Inflammation, 

Division of Inflammation into 
varieties, 

Phenomena of Inflammation, 

Terminations of Inflammation, 
with a short account of the 
Effects of Inflammation on 
the principal Tissues, 
Chap. II.— On Fever, 

History of the General Doctrines 
of Fever, 

[Physiological Doctrines,] 

Division of Fevers, 

General Description of the Phe- 
nomena of Fevers, 

Causes of Fever, 
Chap. III. — Intermittent Fever, 

Appearances found on Dissec- 
tion, 

Causes of Intermittents, 

Pathology of Intermittents, 

Treatment of Intermittents, 

Chap. IV. — Maliokaict, Kemitti.nt 

oa Vi.u.iiw Frnrtt, 

Appearances found on Dissec- 
tion, 

Treatment, 
Infantile Remittent, 

Appearances on Dissection, 

Treatment, 

("hai-. V*. — CnvriMi n Fkveii, 

Fever from Functional Derange- 
ment; 
Treatment, 
Fever from Inflammation, 

Treatment of Inflammatory Fe- 
ver, 

Fever, 
Pathology of Congestive Fever, 
Treatment of Congestive Fever, 



Page 



Page 





Mixed Form of Fever, Typhus and 






Synochus, 


130 




[Typhoid Fever,] 


134 




Hectic Fever, 


141 




General Pathology of Eruptive Fe- 






vers, 


143 




Scarlet Fever, 


148 




Appearances on Dissection, 


153 




Treatment, 


153 




Measles, 


158 




Appearances on Dissection, 


162 


15 


Treatment, 


163 


21 


Small-Pox, 


164 




Appearances on Dissection, 


166 


23 


Treatment, 


167 


23 


Modified Small-Pox, 


168 




[Varioloid,] 


168 




[Cow-Pox and Vaccination,] 


171 




Chicken-Pox, 


176 


25 


Miliary Fever, 


177 


30 


Roseola, 


178 




Urticaria, 


179 


30 


The Plague, 


181 



50 

PART II.— DISEASES OF THE 
51 ORGANS CONNECTED WITH 
56 THE DIGESTIVE SYSTEM. 



Chap. I. — Difficult Dentition, 188 

Chap. II. — Difficult Deglutition 
from Inflammation, Ui.i k- 
hation and Enlargement 
of the Tongue; CrwAifCHE 
Tonsillaris ; Cvn vvciie 
Phahyxoea; Inflammation 
axd Ulceration of the 
Oesophagus, 192 

[Mumps,] 191 

Cynanche Tonsillaris, 195 

Inflammation of the Uvula, 197 

Inflammation of the Pharynx, 198 

Inflammation and Ulceration of the 

(Esophagus, 198 

Chronic Affections of the (Eso- 
phagus, 199 
[Diptheniis,] 200 
Chap. ITL-— Ijtdisesttoit, 201 
Flatulency and Tympanitis, 205 
Pyrosis or Water-brash, 205 
Heartburn, 206 
Gastrodynia, 206 



CONTENTS. 



Chap. IV. — Discharges of Blood 
from the Stomach asd 
Bowels, 

1. Haemorrhage from the Stomach, 

2. Haemorrhage from the Bowels, 
Piles, 

Chap. V. — Common Colic ; Pain- 
ters' Colic; Ileus; Intus- 
susception; Intestinal 
Concretions; Prolapsus 
Ani; and Constriction of 
the Rectum, 
Common Colic, 
Painters' Colic, 

Appearances on Dissection, 
Treatment, 
Ileus, 

Appearances on Dissection and 

Pathological Remarks, 
Treatment, 
Intussusception, 
Intestinal Concretions, 
Prolapsus Ani, 
Constriction of the Rectum, 
Chap. VI. — Intestinal Worms, va- 
rieties of, 

Symptoms and Treatment, 
Chap. VII. — Inflammatory Affec- 
tions of the Organs con- 
tained within the cavity 
of the Abhomen, 
General Remarks on Inflamma- 
tion, 
Enteritic Inflammation, 
Peritonitis, 
Pathology, 
Treatment, 
Puerperal Peritonitis, vulgarly 
called Puerperal Fever, 
Appearances on Dissection, 
Pathological Remarks, 
Treatment, 

Comparative Results of do., 
Chronic Peritonitis, 
Appearances on Dissection, 
Treatment, 
General Remarks on Inflamma- 
tion of the Mucous Mem- 
brane of the Stomach and 
Bowels, 
Inflammation of the Mucous Mem- 
brane of the Stomach, 
Appearances on Dissection, 
Treatment, 
Inflammation of the Mucous Mem- 
brane of the Bowels, 
Treatment, 
Chronic Inflammation of the Mu- 
cous Membrane, 
Diarrhoea, 

Treatment, 
Bowel Complaints of Children, 

Treatment, 
Tabes Mesenterica, 



Page 



Dysentery, 271 

"Symptoms of Chronic Dysen- 
tery, 272 
Appearances on Dissection, with 

Pathological Remarks, 273 

Treatment, 277 

1st. Treatment as it occurs 

in this country, 277 

2d. Treatment as it occurs 
in warm climates, 278 

Treatment of Chronic Dysen- 
tery, 281 
Cholera, 282 
Cholera Morbus, 282 
Treatment, 283 
Asiatic Cholera, 284 
[Geographical Sketch,] 284 
Phenomena, 289 
Causes, 293 
Morbid Appearances, 296 
Morbid Appearances — Collapsed 

Stage, 227 

Morbid Appearances — Third 

Stage, 
Pathological Remarks, 
Treatment, 

For First Stage, 
For Second Stage, 
For Third Stage, 
Saline Injection, 
Inflammation of the Muscular 

and Cellular Tissues, 
Scirrhus of Stomach and Intes- 
tines, 
Symptoms of Cancer in the 

Stomach, &c, 
Treatment, 
Chap. VIII. — Diseases of the Liver 

and Spleen, 324 

Inflammation of the Liver, 324 

Symptoms of Acute Hepatitis, 324 
Symptoms of Chronic Hepatitis, 326 
Appearances on Dissection, 
Treatment, 
Jaundice, 
Treatment, 
Gail-Stones, 
Inflammation of the Spleen, 



SOI 
803 
806 



810 
811 



318 
320 



381 
388 



327 
328 
331 
332 
332 
334 



PART in.— DISEASES OF THE 
ORGANS CONNECTED WITH 
THE RESPIRATORY SYSTEM. 

Chap. I. — General Remarks, 345 

Chap. II. — Diseases affecting the 
Mucous Membrane of the 
Air-Passages, 352 

Catarrh, 353 

Treatment, 353 

Bronchitis, 353 

Chronic Bronchitis, 357 

Stethoscopic Signs of Acute and 
ChroDic Bronchitis, 358 



CONTENTS. 



Page 
Appearances on Dissection, and 

Pathological Remarks, 359 

Treatment of Acute Bronchitis, 361 
Treatment of Chronic Bron- 
chitis, 363 
Inflammation of the Larynx, 366 
Croup, 368 
Appearances on Dissection, 369 
Pathological Remarks, 370 
Treatment, 371 
CEdema Glottidis, &c. 374 
Crowing Disease, 377 
Treatment, 377 
Hooping-Cough, 378 
Appearances on Dissection, 380 
Pathological Remarks, 382 
Treatment, 385 
Chap. III.— Pneumonia, 390 
Stethoscopic Signs, 392 
Appearances on Dissection, 393 
Treatment, 395 
Chap. IV.— Pleuritis, 400 
Stethoscopic Signs, 401 
Appearances on Dissection, 401 
Treatment, 403 
Chronic Pleuritis, 404 
Empyema, 405 
[Pneumothorax,] 406 
Chap. V. — Hemoptysis, 407 
Appearances on Dissection of 

first variety, 408 

Treatment of first variety, 408 

Symptoms of second variety, 408 
Appearances on Dissection of 

second variety, 409 

Treatment of second variety, 411 
Chap. VI. — Phthisis Pulmonalis, 414 
Stethoscopic Signs, 415 

Appearances on Dissection, 418 

[Pathology of Phthisis,] 420 

Treatment, 426 

[Change of Climate,] 430 

Description of more rare struc- 
tural derangements found 
in the lungs, viz., bodies of 
a cartilaginous, bony, calcu- 
lous and chalky nature, 432 
Melanosis of the Lungs, 433 

Medullary Sarcoma of the Lungs, 436 
Chap. VII.— Asthma, 439 

Pathology, 440 

Treatment, 442 



PART IV.— DISEASES OF THE 
CIRCULATING SVSTEM. 

CaiF. I. — Gkvf.iiai. Rkmmiks, 450 

[Morbid conditions of the blood,] 458 

[Of the blood in plethora,] 4 5!) 

[ in anaemia,] 459 

[ in fevers,] 460 

[ in in II, 'immation,] 461 

[ hemorrhage,] 462 



[Of the blood in dropsies,] 
[ in organic dis- 



eases,] 



in the neuroses,] 



Paae 
462 

462 
463 
465 
467 

470 
471 

475 
477 
479 
480 
480 
481 
482 



Chap. II. — Palpitation-, &c. 
Angina Pectoris, 

Appearances on Dissection and 

Pathological Remarks, 
Treatment, 
Chap. III. — Pericarditis asb Cardi- 
tis, 
Appearances on Dissection, 
Treatment, 
Carditis, 
Appearances on Dissection, 
Treatment, 
[Endocarditis,] 
Chap. IV. — Hypertrophy of the 

Heart, 484 

Stethoscopic Signs of Hypertro- 
phy of the Left Ventricle, 485 
Stethoscopic Signs of Hypertro- 
phy of the Right Ventricle, 485 
Treatment of Hypertrophy of 

the Heart, 486 

Chap. V. — Dilatation of the Heart, 490 
Stethoscopic Signs of Dilatation 

of Left Ventricle, 492 

Stethoscopic Signs of Dilatation 

of Right Ventricle, 492 

Tuberculous Formation, 493 

Atrophy of the Heart, 494 

Rupture of the Heart, 495 

Chap. VI. — Diseases of the Valves, 497 

Appearances on Dissection, 497 

Symptoms, 498 

Stethoscopic Signs of Diseases 

of the Valves, 498 

Treatment, 499 

Chap. VII. — Diseases of the Blood- 

Vessels. 500 

Ossification of the Arteries, 502 

Aneurism, 503 

Treatment, 506 

Inflammation of Veins, 506 

Symptoms, 507 

Phlegmasia Dolens, 507 

Pathological Observations, 509 

Treatment, 510 

Chap. VIII. — Plethora and Exsan- 

guinity, 512 

Plethora, 512 

Causes, 5 1 2 

Treatment, 513 

Exsanguinily, 513 

Treatment, 515 

Cuai'. IX. — Cyanosis on Blue Skin, 517 

Symptoms, 517 

Pathological Opinions, 517 

Treatment, 518 

PART V.— DISEASES OF THE 
BRAIN, AND OTHER PARTS 
OF THE NERVOUS SYSTEM. 



xviii 



CONTENTS. 



Page I 
Chap. I. — General Remarks ox Dis- 
eases of the Brain, &c. 501 
Chap. II. — Inflammation of the 

Membranes of the Bhain 
as it occurs in Adults. — 
Inflammation of the Brain, 
which terminates in Suppu- 
ration and Ramollissement. 
Inflammation of the Mem- 
branes of the Brain as the 
Disease occurs in young 
subjects, commonly called 
Hydrocephalus, 534 

Inflammation of the Membranes as 

it occurs in Adults, 534 i 

Phenomena, 535 

Causes, 538 

Appearances on Dissection, 539 ! 

Treatment, 541 ] 

Inflammation of the Substance of 

the Brain, 546 ! 

Symptoms, 510 

Causes, 549 ! 

Appearances on Dissection, 549 j 

Treatment, 551 

Acute Hydrocephalus, 557 

Appearances on Dissection, 558 j 

Pathological Remarks, 561 I 

Treatment, 562 

Chronic Hydrocephalus, 564 

Appearances on Dissection, 564 
Treatment, 565 

Chap. III. — Diseases of the Spinal 

Marrow, 566 

Inflammation of the Spinal Mar- 
row and its Membranes, 566 
Symptoms, 566 

Causes, 567 

Appearances on Dissection, 567 

Treatment, 567 

[Spinal and Ganglionic Irritation,] 568 



Causes, 

Treatment, 
Neuralgic Pains, 

Causes, 

Treatment, 
Chap. V. — Apoplexy and Paralysis, 
Apoplexy, 

.Symptoms, 

Causes, 

Appdarances on Dissection, 

Treatment, 
Paralysis 

Symptoms, 

Causes, 

Treatment, 
Chap. VI. — Insanity — Hypochon 
driasis — and DELIMU1 
Tri:mk\s, 
Insanity, 

Causes, 

Appearances on Dissection, 

Treatment, 
Hypochondriasis, 

Causes, 

Treatment, 
Delirium Tremens, 



Pas* 
597 
587 
589 
590 
691 
592 
592 

50 ; 

59 1 
595 
596 
596 
598 
598 



601 
601 
602 
604 

(1(15 
fid:* 
610 
610 
611 



PART VI.— DISEASES OF THE 
EYE AND EAR, 619 

Chap. I. — General Remarks on Dis- 
eases of the Eye, 619 

Symptoms of Ophthalmic In- 
flammation, 620 

Causes of Ophthalmic Inflam- 
mation, 621 

Treatment of Ophlhal raic Inflam- 
mation, 622 
Chap. II.--Inflammation of the Con- 
junctiva, 627 



Tetanus, 


571 


Simple Inflammation of the exter- 




Symptoms, 


572 


nal covering of the Eye, 


627 


Causes, 


573 


Svmptoms, 


627 


Appearances on Dissection, 


574 


Treatment, 


628 


Treatment, 


575 


Simple Cartarrhal Ophthalmia, 


628 


Trismus Nascentium, 


575 


Symptoms, 


629 


Hydrophobia, 


576 


Treatment, 


629 


Symptoms, 


577 


Purulent Ophthalmia of Infants, 


630 


Appearances on Dissection, 


577 


Symptoms, 


631 


Treatment, 


577 


Causes, 


C32 


Chap. IV. — Epilepsy — Hysteria- 




Treatment, 


633 


Chorea — and Neuralg 


c 


Pustular Ophthalmia, 


636 


Pains, 


578 


Treatment, 


636 


Epilepsy, 


578 


Chap. III. — Inflammation of the 




Symptoms, 


579 


Eyeball, 


637 


Causes, 


579 


Inflammation of the Sclerotic Coat 


,637 


Appearances on Dissection, 


580 


Inflammation of the Iris, 


637 


Treatment, 


583 


Causes, 


638 


Hysteria, 


584 


Treatment, 


6.39 


Symptoms, 


585 


Amaurosis, 


641 


Causes, 


5S5 


Causes, 


641 


Treatment, 


586 


Symptoms, 


641 


Chorea, 


587 


Treatment, 


642 



CONTENTS. 



Pase 

Chap. IV. — Diseases of the Eah, 644 

Otitis, 644 

Causes, 644 

Treatment, 645 

Otorrhoea, 646 



Page 
Exudation of blood from the sur- 
face, without abrasion of 
the cuticle, commonly called 
" bloody sweat," 708 



PART VIII.— DISEASES OF THE 



PART VII.— DISEASES OF THE 




URINARY AND GENITAL OR- 




SKIN, 


649 


GANS. 




Chat. I. — General Remarks ox Dis- 




Chap. I. — Inflammation of the Ure- 




eases of the Skin, 


651 


thra, Bladder and Kidneys, 


713 


Classification of Diseases of the 




Inflammation of the Urethra, 


713 


Skin, 


651 


Symptoms, 


713 


Chap. II. — Erysipelas, 


652 


Appearances on Dissection, 


715 


Symptoms, 


652 


Treatment, 


716 


Causes, 


654 


Inflammation of the Mucous Mem- 




Appearances on Dissection, 


656 


brane of the Bladder, 


718 


Pathological Remarks, 


658 


Causes, 


719 


Treatment, 


666 


Treatment, 


719 


Chap. III. — Papular Diseases, 


672 


Inflammation of the Kidney, 


720 


Strofulus, 


672 


Symptoms, 


721 


Treatment, 


672 


Treatment, 


721 


Lichen, 


673 


Albumen una, 


721 


Treatment, 


673 


Chap. II. — Calculus in Kidneys, 




Prurigo, 


673 


Bladder, and other parts 




Treatment, 


673 


of the Urinary Passages, 


724 


Chap. IV. — Pustular Diseases, 


675 


Chemical characters of Urinary 




Impetigo, 


675 


Calculi, 


724 


Causes, 


675 


Calculus in the kidney, 


727 


Treatment, 


676 


Symptoms, 


727 


Porrigo, 


677 


Treatment, 


728 


Treatment, 


677 


Calculus in the Bladder, 


729 


Scabies, or Itch, 


681 


Symptoms, 


729 


Causes, 


682 


Treatment, 


729 


Treatment, 


682 


Calculus in the Urethra, 


730 


Ecthyma and Rupia, 


682 


Calculus embedded in the Prostate, 730 


Causes, 


683 


Chap. III. — Suppression of Urine 




Pathology, 


683 


Retention of Urine, In- 




Treatment, 


683 


continence of Urine, 


731 


Acne, 


684 


Suppression of Urine, 


731 


Causes, 


684 


Treatment, 


732 


Treatment, 


684 


Retention of Urine, 


735 


B • $is, 


685 


Treatment, 


735 


Treatment, 


685 


Incontinence of Urine, 


725 


Chap. V.— Squamous Diseases, 


686 


ClIAP. IV.— HEMATURIA, OR DISCHARGE 


Lepra, 


686 


of Blood from the Urinary 


Causes, 


687 


Passages, 


736 


Treatment, 


667 


Treatment, 


736 


Psoriasis, 


689 


Chap. V. — Diaiieteb, 


739 


Treatment, 


690 


Symptoms, 


740 


Pityriasis, 


691 


Appearances on Dissection, 


741 


Causes, 


692 


Causes, 


741 


Treatment, 


692 


Pathology, 


741 


Chap. VI. — Vlshilaii Diseases, 


693 


Treatment, 


742 


Herpes, 


693 


Chap. VI. — Syphilis, 


747 


Causes, 


694 


Symptoms, 


748 


Treatment, 


694 


Treatment, 


749 


Pemphigus and Pompholyx, 


695 


Chap. VII. — Diseases of TBI Laiua 




Chap. VII. — Pi hpuiia, 


S96 


\> n I'xtkun ai. Parts in TH1 




Causes, 


703 


Fkmale, 


757 


Appearances on Dissection, 


704 


Phlegmon, 


757 


Pathology, 


705 


Symptoms, 


757 


Treatment, 


706 


Treatment, 


757 



CONTENTS. 



Page 
Peculiar Affection of the Pudendum, 

occurring in young subjects, 759 
Treatment, 760 

Chap. VIII. — Inflammation of the 

Testes, 761 

Treatment, 761 

Chap- IX. — Diseases of the Uterus, 

CONNECTED WITH INFLAMMA- 
TORY ACTION 763 

Inflammation, of the Uterus after 

delivery, 763 

Inflammation of the Os and Cervix 
Uteri in the ordinary state 
of the system, 765 

Treatment, 766 

Vascular Sarcoma of the Uterus, 767 
Treatment, 768 

Scirrhus and Cancer of the Uterus, 769 
Treatment, 770 

Chap. X. — Prolapsus of the Uterus 
— Retroversion of the 
Uterus — Polypus op the 
Vagina and Uterus, 772 

Prolapsus of the Uterus, 772 

Causes, 772 

Treatment, 772 

Retroversion of the Uterus, 773 

Causes, 773 

Treatment, 773 

Polypous Tumours of the Vagina 

and Uterus, 774 

Treatment, 776 

Chap. XI. — Tubercles of the 
Uterus — Bony Concre- 
tions — Hydatids, A q.ueous 
and Flatulent Discharges, 777 
Tubercles of the Uterus, 777 

Treatment, 778 

Bony Concretions, 778 

Treatment, 779 

Hydatids, 779 

Aqueous and Flatulent Discharges, 780 
Chap. XII. — Fluor Albus and Leu- 

CORRH02A, 780 

Symptoms, 781 

Causes, 782 

Treatment, 782 

Chap. XIII. — Diseases of Menstrua- 
tion, 785 
Amenorrhoea, 785 



Pagp 

Retention of the Menses, 785 

Causes, 789 

Treatment, 791 

Suppression of the Menses, 791 

Treatment, 791 

Dysmenorrhoea, or Painful and 

Difficult Menstruation, 792 

Pathological Remarks, 794 

Treatment, 795 

Immoderate Flow of the Menses, 798 

Treatment, 798 

Menorrhagia, 798 

Causes, 799 

Treatment, 800 

Cessation of the Menses, 804 

Treatment, 805 

Chap. XI V. — Diseases of the Ovahia,806 

Symptoms, 806 

Treatment, 809 



PART IX. — GOUT — RHEUMA- 
TISM— SCROFLL A— DROPSY, 817 

Chap. I— Gout, 817 
Phenomena of a Paroxysm of 

Regular Gout, 818 

Phenomena of Chronic Gout, 822 
Phenomena of Retrocedent Gout, 824 
Causes of Gout and Pathological 

Observations, 827 

Treatment, 831 
Management of Gouty Subjects 

during the intervals, 834 

Chap. Tl. — Rheumatism 837 

Acute Rheumatism, 837 

Symptoms, 837 

Treatment, 839 

Chronic Rheumatism, 842 

Rheumatic Gout. 843 

Chap. III. — Scrofula, 845 

Treatment, 84S 

Chap. IV.— Dropsy, 853 

General Remarks, 853 

Anasarca, 872 

Treatment, 872 

Hydrothorax, 872 

Stethoscopic Signs, 873 

Treatment, 873 

Ascites, 873 



PART I. 



GENERAL HISTORY OF INFLAMMATION AND FEVERS.- 

WITH THE PATHOLOGY AND TREATMENT OF 

INDIVIDUAL FEVERS. 



CHAPTER I. 

ON INFLAMMATION 



HISTORY OF THE GENERAL DOCTRINES, CAUSES, PHENOMENA, AND 
EFFECTS OF INFLAMMATION. 

In the history of Medical Science, we find no subject has attracted 
more attention than that of inflammation; the minds of the most 
distinguished pathologists having been turned to the investigation 
with an ardour which has never been surpassed. This is to be 
attributed to the importance of the subject— to the frequent occur- 
rence of inflammation — and to the wide range of diseases which 
owe their origin to this morbid action. According to many authors, 
inflammation and fever are thought to be mere modifications of the 
same pathological state of the system, while others speak of them 
even as synonymous terms; hence, a successful elucidation of the 
former was expected to prove a triumph over the difficulties of the 
latter. 

This interesting subject still continues to command the attention of 
every new inquirer — doubtless owing to the mystery in which he 
finds it involved; for it must be confessed, that notwithstanding the 
indefatigable labours of John Hunter and others, it does not appear 
that any very strong light has been thrown on the true pathology of 
inflammation ; while it could easily be proved that much obscurity 
has been produced, by confounding cause and effect, and by regard- 
ing some of the phenomena as principal parts of the essence of 
inflammation. A great mistake has also been committed by medical 
inquirers following out an erroneous method of investigating dis- 
eases, forming false analogies, and attributing to inflammation of 
internal organs, all the phenomena and characters of those situated 
on the surface of the body— thus drawing too largely from surgical 
pathology. But it may be stated, that the most deadly inflammation 
of important organs may proceed to a fatal termination, some with 
few, others with none of the symptoms hitherto universally attributed 
to inflammation. 

In giving a history of the doctrines which have prevailed, it would 
be a waste of time to quote the opinions maintained previous to the 
time of Boerhaave, because they were inconsistent with the know- 
ledge we now possess of the circulation of the blood. Boerhaave 
insisted that inflammation is produced by an obstruction to the free 
circulation in the capillary vessels. Obstruction, he conceived, might 
be occasioned by too profuse a flow of any of the excretions, and by 



16 INFLAMMATION. 

heat, or the application of any other cause which dissipated the 
thinner parts of the blood, thereby producing viscidity. When this 
thickened state of the blood did not exist before the production of 
inflammation, he imagined that the larger globules of the blood found 
their way by some accident into the capillaries, and produced ob- 
struction. But when the perspiration, the flow of urine, or any of 
the other excretions were suppressed, then he supposed the capil- 
laries became so much distended as to allow the thicker parts of the 
blood to enter, creating a more permanent obstruction ; and this state 
he termed an error loci. Thus, it will be seen that Boerhaave had 
two causes of inflammation — viscidity of the blood, and an error 
loci, either of which he supposed capable of producing an obstruc- 
tion in the circulation of a part, giving rise to increased action in the 
heart and other vessels, and exciting a flow of blood in the direction 
where the obstruction existed. He, however, felt the necessity of 
having the assistance of some other cause to enable him to account 
more satisfactorily for the morbid terminations which occasionally 
happen, and therefore brought into play the humoral pathology, by 
stating that there is sometimes an acrimonious state of the fluids, 
which tends to produce gangrene. 

That part of his doctrine relating to viscidity cannot support the 
phenomena; the viscidity being more likely to produce a general 
than a local effect, since the whole mass of blood must be supposed 
to be in the same state. But there is rather more probability in the 
error loci; for it is a fact, that in inflamed parts, red blood enters into 
vessels which, in a state of health, circulate only a colourless fluid. 
But here there is some difficulty in determining whether or not the 
error loci is an effect, and not a cause of inflammation ; and the 
difficulty is increased, when we reflect, that vessels frequently cir- 
culate red particles, which usually contain a colourless fluid, and 
yet inflammation has neither preceded, attended, nor followed this 
remarkable change. 

On looking at the history of medical opinions on this subject, we 
shall observe that, as the humoral pathology declined Boerhaave's 
doctrines began also to lose ground, although the phenomena of in- 
flammation were, in many cases, ingeniously explained by their as- 
sistance; and it must be confessed that we have abandoned this doc- 
trine, which is far more ancient than the time of Boerhaave, without 
sufficient consideration. 

Stahl and Hoffman attempted to improve Boerhaave's doctrines, 
by bringing into account the influence of the nervous system on the 
capillary vessels in inflammation. On this occasion, little need be said 
respecting the views of these celebrated men, as it will be necessary 
to resume the subject in a subsequent part of the work. But it may 
be noticed, that it has always appeared to me a strong proof of the 
close connection between the state termed fever, and that of inflam- 
mation, that almost every individual labourer in this field of investi- 
gation has adduced the same, or nearly the same doctrines, to explain 
the phenomena of both. Hence the pretty general belief as to their 
identity. But it will soon be my duty to offer many reasons for dis- 
senting from this too sweeping pathology. 



INFLAMMATION. 17 

This slight notice of the opinions of Boerhaave, Stahl and Hoffman, 
is sufficient to enable me to connect their views with those of modern 
date. The doctrines taught by Cullen were founded upon those of 
the last three physicians. He admitted the obstruction so much in- 
sisted on by Boerhaave, but denied that it was produced either by 
error loci, or lentor of the blood. He also took advantage of the hint 
which had been given by Stahl and Hoffman respecting the influence 
of the nerves, and insisted that the obstruction was produced by 
"spasm of the extreme arteries, supporting an increased action in the 
course of them." Cullen maintained this doctrine even in those 
cases in which external inflammations are occasioned by the appli- 
cation of boiling water, blisters, and other stimuli. 

The only observation it appears necessary to make, after giving 
this slight sketch, is that all these illustrious physicians have been 
guilty of confounding cause and effect. When we place a ligature 
upon a large vessel, we do not find that general inflammation of the 
limb follows as a matter of course, which, nevertheless, ought to 
happen if mere obstruction were the cause of inflammation. This 
obvious objection has not escaped authors; and it has also been re- 
marked by the acute mind of Allan Burns, that the effusion from the 
capillaries into the cellular membrane, which takes place so frequently 
as the effect of inflammation, cannot be explained if the doctrine of 
spasm be admitted. Besides, Cullen has been guilty of a logical 
blunder, in attributing the proximate cause of inflammation to spasm 
of the capillaries, when, according to his own showing, the spasm is 
occasioned by an accumulation of blood in these vessels. 

According to John Hunter, inflammation is to be considered only 
as a distracted state of parts, which requires another mode of action 
to restore them to a state of health; or, in other words, that inflam- 
mation is a healthy action, which follows an injury of some tissue or 
organ. In another place, he states that active inflammation is to be 
considered as an increased action of the vessels, which consists sim- 
ply, in the first instance, in a distention beyond their natural size. 
This he supposes to depend on the elasticity of the vessel, and a 
weakness of its muscular power. The whole of this he considers as 
a law of nature ; and he seems to have believed, that the blood-ves- 
sels possess within themselves an innate active power of dilatation. 

This leads me to state, that two modern opinions on this subject 
divide the profession. According to the one, inflammation depends 
upon increased action of the capillaries of the part. According to the 
other, it is produced by debility or weakened action of the same 
vessels, and increased action of the trunks. On each side of this 
intricate and difficult question are ranged the names of very eminent 
men; but, as will be shown in the Bequei, they might have spared 
themselves a great deal of trouble. Both parties found their opinions 
upon microscopical experiments performed on the web of the frog's 
foot. Each observed the same phenomena, but they have drawn 
different conclusions. Dr. Thomson, for instance, applied salt to a 
frog'.s foot; (Ik; first effect was to increase the velocity of the circula- 
tion, and to make the vessels larger to the naked eye, and of a brighter 
red colour. After the stimulant had been continued some time longer, 

2* 



18 INFLAMMATION. 

the red globules became "less distinct than before the application of 
the salt, and obviously less distinct from the rapidity of their mo- 
tion." 

Dr. Wilson Philip performed experiments, prior to Dr. Thomson, 
on the frog's foot; and having first proved that he could create in- 
creased action in the capillaries without exciting inflammation, hap- 
pened to meet with one unfortunate frog, who had already by some 
means contracted inflammation ; and he found, upon applying the 
microscope, the vessels greatly dilated, and the motion of the blood 
extremely languid ; — and he says, " It was at once evident, on ob- 
serving the part through the microscope, that where the inflammation 
was greatest, the vessels were most distended, and the motion of the 
blood was slowest." 

Dr. Wilson Philip wetted the web of the frog's foot with distilled 
spirit, but although he continued to keep it moist for ten minutes, or 
a. quarter of an hour, he could not perceive the slightest symptoms 
of inflammation. " The vessels, instead of appearing redder and 
more turgid, were evidently paler and smaller than before the ap- 
plication of the spirits." No wonder. Distilled spirit is the most 
deceitful application he could have used for such an experiment. In 
the first place, it might stimulate the circulation in the part, but its 
quick evaporation would necessarily produce coldness, which, no 
doubt, caused contraction of the vessels, and rendered them paler 
and smaller. 

Dr. Hastings has subsequently repeated these experiments, cor- 
roborating those of the last named author. In all the experiments, 
whether performed by Thomson, Wilson Philip, or Hastings, the 
velocity of the blood is represented to have been increased in the 
capillaries, in the state of simple excitement; but it constantly hap- 
pened, when inflammation commenced, that no globules could be 
seen in the blood of the affected vessels. Now, whether are we to 
join Dr. Thomson in concluding, that they cannot be seen because of 
the " rapidity of their motion" or Dr. Hastings and others, who 
state that the blood in an inflamed part, becomes itself morbidly 
changed, so that no globules can be detected ? The point in dispute 
is thus brought within a very small space, and the reader is left to 
form his own opinions. The result of my investigations on this sub- 
ject shall now be detailed ; and it may be stated, that this has not 
been done hurriedly, but after considerable experience, and a very 
careful review of all that has been written on inflammation. 

It appears to me that the view taken by Mr. Syme, in an essay 
on inflammation,* is the most correct. He thinks that too much 
attention has been directed to the obvious signs of inflammation, viz., 
redness, heat, swelling, and pain, and too little bestowed on the al- 
tered functions of the part. Mr. Syme justly thinks, that "if this 
remarkable character of inflammation had been kept in mind, patho- 
logists would hardly have spent so much labour in disputing about 
contraction and dilatation of the vessels, since it is obvious, that mere 
difference of capacity, though it might, to a certain extent, account 

* Published in Edinburgh Med. and Surg. Journal, vol. 30, p. 316. 



INFLAMMATION. 19 

for the redness and swelling, could never enable us to explain the 
alteration of function, any more than a knowlege of the size of capil- 
lary vessels could instruct us as to the mode in which their secre- 
tions, &c, are performed during health." — And he maintains, that 
" redness and swelling ought to be secondary considerations in the 
investigation of the inflammatory state, in comparison with the grand 
distinguishing character of altered function" 
■ Three points seem to have been much overlooked by writers on 
inflammation. Is/, The influence of the nervous system ; 2d, The 
changes in the qualities of the blood itself; and 3d, The disordered 
functions of the capillaries. I have performed experiments upon 
horses, which prove most satisfactorily the influence of the nerves, 
even in chronic inflammation. It is well known that these animals 
are very liable to inflammation in the foot, from different causes; and 
I have seen horses, which have been lame for months, cured by divid- 
ing the nerves immediately above the fetlock joint, the effect being 
sometimes instantaneous, and occasionally permanent. With regard 
to the second point, there can be no doubt that the blood in the part 
affected becomes diseased; the red particles cease to be observed, and 
the blood assumes a flocculent appearance, becoming darker and 
darker, and the vessels become in some degree obstructed. It is not 
improbable that this change on the blood may be found to depend 
partly, if not principally, upon the cessation of nutrition and exhala- 
tion, and at the same time a stop being put to the conversion of arte- 
rial into venous blood. 

It has been long known, that increased action of the vessels does 
not constitute inflammation, as we see every day illustrated in the 
act of blushing, and by the employment of friction to any part on the 
surface of the human body. In these instances, the vascularity soon 
subsides on the removal of the causes. But we can produce actual 
inflammation by a continuance of the friction; the blood will accu- 
mulate, and wc shall have all the phenomena, and the usual effects 
of slight superficial inflammations. It may be produced also by 
obstructing the flow of blood in the limb for a sufficient length of 
time by applying a ligature, and this is what actually happens in a 
case of strangulated hernia. 

Diminished action of the vessels may be produced and maintained 
for some considerable time, and the effect will perhaps be, not in- 
flammation of the part itself, but of another part of the body at a 
distance. Again, if inflammation has been excited in an organ, an 
increased flow of blood takes place towards it, and all other parts 
must consequently suffer from a diminished supply of arterial blood; 
this increases the embarrassment in all organs — hence the general 
constitutional disturbance. In the practice of physic this last circum- 
stance is too frequently overlooked. Physicians are apt to expect a 
cessation of the constitutional symptoms the moment the original 
disease is subdued; this not being the case, they often push their 
remedies fir beyond the proper point, and make matters worse. This 
.^. perhaps, more peculiarly a British error, and we are justly con- 
demned lor it by our continental brethren. Other physicians, again, 
do very great mischief by stimulating and throwing in bark and other 



20 INFLAMMATION. 

tonics too soon after convalescence has commenced;— they will be 
found in the morning ordering a large bleeding, and in the evening 
a stimulant. Cases no doubt occur in which a more immediate change 
of treatment may be necessary; all that is wished to be impressed 
upon the reader in this part of the work, is, that such practice is too 
often had recourse to, more from an unfounded dread of the occur- 
rence of " typhoid symptoms," than from real necessity ; and that 
sufficient confidence is not placed in the powers of the constitution, 
to repair injuries which have been sustained. Physicians are too 
often found tampering with the human frame, as if it resembled a 
piece of machinery of their own construction. 

The essence of inflammation partly consists in more blood entering 
by the arteries than can escape by the veins, or than can be made use 
of, as when the part is in a state of health, when its functions are 
actively performed; the consequence is an accumulation of blood, or 
congestion and effusion from partial obstruction ; and it is, I imagine, 
this degree of obstruction which produces the throbbing. The vessels 
of the inflamed part are greatly dilated, and the number which con- 
tain red blood is greatly increased. 

It must be confessed, that in inflammation there is much undis- 
covered. Physiologists have to settle several disputed points in the 
doctrines of the circulation ; and anatomists have to discover a great 
deal regarding the anatomy and physiology of the capillary and 
nervous systems, before pathologists can be expected to advance 
their part of the science of medicine in any remarkable degree. 

Considerable difference of opinion still exists among physiolo- 
gists, whether the circulation of the blood in the capillaries depends 
entirely upon the vis a tergo it receives from the heart, or whether 
these vessels possess an impulsive power independently of the heart's 
action. Those who examine this subject without preconceived 
notions, and with no other view than to discover truth, cannot reject 
the vis a tergo which the whole column of blood is regularly re- 
ceiving from the heart. Neither can they reject the action which 
the vessels possess from their elasticity, in aiding other parts of the 
machinery, not to mention their power of contracting themselves 
even into a much smaller diameter than is natural to them, when 
circumstances require it for the preservation of life. With respect 
to the first point, it will be observed, that if one of the smallest 
arteries in the body, and at the greatest possible distance from the 
heart, be divided, the blood will be perceived to flow per saltiim, 
the jets corresponding to the actions of the heart. As to the second 
point, if the extreme vessels are quiescent, not possessing any power 
of action within themselves, and depending entirely upon the action 
of the heart, how could irregular determinations of blood take place? 
When any internal organ is inflamed, we are taught, by experience 
and observation, to apply blisters and other irritants to the surface 
of the body, as a part of the remedial process. These applications 
excite a temporary inflammation on the surface, sometimes to the 
complete relief of the internal disease. This translation, as it may 
be called, is not effected through the agency of the heart, by the con- 
tractions of which the blood is propelled into the vessels generally; 






INFLAMMATION. 21 

it can, in all probability, have no power to send blood to one part, 
in preference to another. 

The results of experiments lead me to believe that some notable 
errors or oversights have been committed by Hunter, and many 
other experimenters upon the circulation. In the essay above 
alluded to, Mr. Syme, in endeavouring to refute the received notions 
respecting the circulation in the capillaries, makes the following 
statements : — " In this case, also, we ought to discover, through the 
microscope, not only a change in the capacity of the capillaries, but 
an oscillatory movement of the globules passing through them. 
Instead of this, we see the capillaries apparently quite rigid and 
immovable, while the globules shoot through them in such a free, 
unconstrained manner, as to convince every observer that they are 
not impelled by a vis ct, tergo." The results of one of Mr. Syme's 
experiments are worthy of being quoted in his own words: — "I 
have repeatedly seen the globules continue in motion through the 
capillaries of a frog forty minutes after the whole heart was excised. 
And this motion was not uniform — either as to direction or velocity, 
in which case the gradual contraction of the vessels might have been 
supposed adequate to account for it — but sometimes this way, some- 
times that — at one time quick, at another slow — and always con- 
tinuing quickest as well as longest in the smallest vessels. While in 
health, the motion of the blood is slowest in the capillaries." 

Having been an eye-witness to these experiments, I can add my 
testimony as to their correctness, and that every precaution was taken 
to guard against the possibility of any fallacy. 

Before concluding this subject, I beg to enter my protest against 
the employment of the term "debility," as too generally applied to 
the capillary vessels of an inflamed part. If a man were able to 
walk three miles in an hour with an ordinary burden on his shoulders, 
it surely would not be correct to say he is in a state of debility, be- 
cause he could not go over as much ground if he had to carry an 
additional hundred-weight. This is exactly the condition of the 
blood-vessels; they are well able to perform their natural functions, 
but when over-loaded, they are rendered incapable. 

Causes of Inflammation. 

In stating the causes of inflammation, it is my intention to avoid 
adverting to occult causes. In medical investigations, it is very in- 
jurious to science to affect being overwise, and it is surely more 
philosophical to confess our ignorance, than to attempt, by special 
pleading, to leap over difficulties which, in the present stale of our 
knowledge, are insurmountable. Instead of descanting at great length 
upon proximate, remote, exciting, and predisposing causes, it will be 
better to speak of common and specific causes of inflammation. 
The disease itself is improperly termed by Ctlllen and others, the 
" proximate cause;" this term will, for a considerable time to come, be 
fostered by symptomatica! physicians, who call the symptoms the 
disease, and the disease the proximate cause; but there is no reason 
why it should be retained in this work, unless it were employed to 



2-2 INFLAMMATION. 

denote the proximate cause of the symptoms. As to predisposing 
causes, it is more consistent to take them into consideration when 
treating of prevention of diseases; but many writers have been 
guilty of great absurdities even with regard to their influence in the 
production of disease. One author, with whose writings most medi- 
cal men are well acquainted, in treating of the predisposing causes of 
hooping-cough, mentions, among others, "a serous temperament — 
a scrofulous constitution — dentition — a disposition to contract ca- 
tarrhal affections — the retrocession of eruptive diseases." 

The common causes in the production of internal inflammation 
are, exposure to cold ; sudden vicissitudes of weather, particularly 
when the air is damp; irregularity of bowels; unwholesome diet; 
insufficient clothing; cold drinks, particularly when the body is 
warm ; depressing passions, &c. Almost all these causes tend to pro- 
duce inflammation in the same manner, by inducing irregular dis- 
tributions of the blood and venous congestion. The lost balance of 
the circulation is marked sufficiently well in the beginning of almost 
all acute diseases, by the accession of rigours, coldness, and paleness 
of the surface of the body. Some individuals are more liable to in- 
flammatory attacks than others, and some to inflammation of a par- 
ticular tissue or organ. Such persons may well be said to be liable 
to, or susceptible of, such disease ; there can therefore be no objection 
to the term in this limited application. 

Few persons escape inflammatory affections produced by specific 
causes. The contagion of small-pox is termed a specific cause, be- 
cause nothing is capable of producing the disease but its own conta- 
gion, in whatever way it is communicated. Measles is produced by 
a specific cause. Scarlatina also, and perhaps hooping-cough. Ery- 
sipelas is not to be ranked with these specific diseases, because it is 
not produced by a specific cause, as is too generally imagined. If 
erysipelas were produced twenty times, by inserting matter taken 
from an erysipelatous surface, expressly for the sake of experiment, 
still it cannot be ranked as a specific disease, because it has also fol- 
lowed an injury produced by a splinter of wood, a perfectly clean 
sewing needle, a rusty nail, &.c. It has also occurred after a prick 
received in dissection. No one ever alleged that small-pox, measles, 
or scarlatina, were ever produced in this fortuitous manner. It may 
be also mentioned, that there are other matters, the nature of which 
is unknown, but the effects of which are capable of producing in- 
flammatory affections, viz., malaria, sometimes denominated marsh 
miasm, and human effluvia, together with another and still more 
mysterious agent, epidemic influence. But it appears to me, the great 
agent in the production of inflammatory affections is the sudden 
application of cold to the surface of the body, particularly when the 
stomach and bowels are out of order, and the mind depressed. Cold 
wet feet, for example, will sometimes produce determination to the 
head, and phrenitis will be the consequence; or to the lungs, pro- 
ducing pneumonic inflammation, &c. Dr. Thomson, in his work on 
inflammation, states that this cannot be explained upon any prin- 
ciple. The doctrine of determination of blood explains it so far, 
and in my humble opinion quite far enough for all practical purposes. 



INFLAMMATION. 23 

It is not, however, actual, but relative cold, which is so prejudicial to 
the human body; it is exposure to cold when the body has been pre- 
viously much heated. 

An individual, after sudden exposure to a cold damp atmosphere, 
may be attacked by inflammation of the lining membrane of the air 
passages. It becomes an interesting and important question to de- 
termine upon what part of the human frame the cold air acts. Dr. 
Thomson says, at page 57 of his work on inflammation: "In some 
instances, cold, or a diminution of temperature, seems to act more 
directly upon the parts with which it comes in contact. We have 
proof of tli is in the inflammation of the mucous membrane of the 
nose, fauces, trachea, and bronchiae, from the inhalation of cold air." 
This is a most unhappy illustration. It is apparently a matter of little 
consequence how cold the air is that passes into the lungs, provided 
the body be sufficiently protected by warm clothing. In cold regions, 
if Dr. Thomson's hypothesis were true, an individual ought never 
to be free from bronchitis. We are assured, however, that the sailors 
in the voyages of discovery, which were made by Captain Parry and 
Captain Ross to the North Pole, enjoyed remarkably good health. 

There is another curious point which must be noticed. Extreme 
cold produces exactly the same sensations and the same effects upon 
the living animal fibre as intense heat. Take a piece of frozen mer- 
cury in the hand, and it will cause a sensation similar to that pro- 
duced by hot iron — inflammation and vesication follow; and if ap- 
plied long enough, destruction of the part will take place. The hot 
iron destroys vitality by the addition of too much caloric; the frozen 
metal, by abstracting it too suddenly. 

Division of Inflammation into varieties. 

Inflammation has been variously divided and subdivided. The 
terms acute, sub-acute, and chronic, shall be employed in the course 
of this work, as being sufficiently precise, and well understood. It 
is wished to avoid the use of the term " passive," because it is em- 
ployed loo vaguely, sometimes to express the existence of sub-acute 
inflammation, at others that of the chronic kind. John Hunter also 
instituted the terms healthy and unhealthy. Is inflammation a dis- 
ease? If it. bo, it is certainly not proper to call it healthy. Other 
varieties of inflammation have been mentioned, as scrofulous, gouty, 
rheumatic, erythematic, erysipelatous, &c.; but it is my belief, that as 
pathology improves, these terms will be less frequently employed. 
Another obvious division of inflammation depends upon the tissue or 
organ affected. 

Phenomena of Inflammation. 

External inflammation is characterized by redness, swelling, heat 
and pain. All these taken together, leave no doubt as to the existence 
of inflammation. In this respect, surgeons have the advantage of 
physicians. They can see and fuel the part affected, in addition to 
the power of judging from the constitutional symptoms, and the ac- 
count the patient gives of his own sensations. Whereas in physic 



24 INFLAMMATION. 

we have greater difficulties to encounter in forming a diagnosis. We 
observe local and constitutional symptoms also; but it does not 
always follow, because there are dyspnoea and fever, that the lungs 
are inflamed; the disease may be inflammation of the pericardium. 
There may be violent vomiting, tenderness in the epigastrium, thirst, 
with more or less fever, while the disease is in the head. There may 
be severe local and constitutional disturbance, without the existence 
of the slightest degree of inflammation, merely from a neuralgic 
affection of some tissue or organ, or from impeded function of 
some viscus. During life we cannot see the state of internal organs, 
to ascertain whether they are red and swollen; and a sensation of 
heat, pain, and fever, may exist without the least inflammatory 
action. It will be proved, in a subsequent part of this work, that 
the pulse cannot be depended on. With respect to burly blood,* it 
may exist without actual inflammation; and, in inflammatory com- 
plaints, the blood does not always yield it. The shape of the dish 
modifies this appearance, as does the manner in which the blood 
flows from the vein. Mental agitation and fatigue produce the buffy 
coat. Sometimes it does not appear on the blood till the patient has 
been largely and repeatedly bled. I am inclined to place considera- 
ble dependence, however, on the buffy coat, taken in connection 
luith other circumstances, particularly when the surface is also con- 
cave, or "cupped," as it has been termed, and when the quantity of 
serum is proportionably large. 

It has often occurred to me to see dissections where great destruc- 
tion of vital organs had taken place from inflammation, and yet there 
had been little or no pain complained of during life. Nay, I have 
seen instances of inflammation of the pleura to such a degree as to 
occasion death, where the symptoms were too slight to direct the 
medical attendants to the true seat of the disease. 

No pathological physician will join Dr. Gregory, a modern writer 
on the Practice of Physic, in the following dogmas: "Delirium 
marks inflammation of the brain; impatience of light, ophthal- 
mia; hoarseness, inflammation of the larynx ; and dyspnoea, that 
of the lungs." The practice of physic would, indeed, be simple and 
certain, were these things true. But this is not the proper place 
to enter upon a refutation of such arbitrary and erroneous assump- 
tions. 

The uncertainty of the pulse has been already mentioned. In- 
flammation may be going on towards a fatal termination, in an 
important organ, without any febrile movement. This was noticed 
long ago by Morgagni, Valsalva, and others, and it led them too 
hastily to conclude, that mortification of internal organs occasionally 
took place without the previous existence of inflammatory action. 

What occasions the redness, swelling, heat, and pain, in external 
inflammations? The redness is occasioned, no doubt, by the enlarged 

* Blood is said to be "buffy," when the surface, inslead of being of a reddish 
colour, presents a yellowish crust of greater or less thickness. There are various 
opinions as 10 the cause of this appearance. Some attribute it to the slower coagu- 
lation of the blood; others to an increased quantity of fibrine; or merely to the hur- 
ried state of the circulation. Of one fact I am quite certain, from repeated observa- 
tions, that blood may be seen to be buffed while it is yet flowing from a vein, and 
before the stream has reached the cup. 



INFLAMMATION. 25 

size of the vessels, and the increased quantity of blood in the part 
affected. Vessels, which formerly transmitted a lymphy fluid, now 
circulate red blood. 

The swelling has been erroneously ascribed to the expanded state 
of the blood from increased heat ; but it has been proved that the 
blood contained in the vessels of an inflamed part, is not one degree 
hotter than that which flows from the heart ; besides, a few degrees 
of caloric could have no effect in producing the swelling. It seems 
to be owing to the increased quantity of blood in the part, and the 
effusion of a lymphy fluid into the surrounding cellular substance — 
the action of the absorbents being at the same time, in all proba- 
bility, interrupted. 

Heat.— Boerhaave and others imagined that this symptom de- 
pended on the friction of the red globules against the sides of the 
vessels, and that, in inflamed parts, the friction is greatly increased 
by the obstruction which exists. This, like all Boerhaave's doc- 
trines, is too mechanical. It is difficult to determine on what cause 
the increased heat depends, and fortunately for humanity, it is not 
of much consequence ; but it is probably in part owing to a peculiar 
action in the nerves of the texture, partly to the increased volume of 
blood, by which the quantity of caloric is augmented, although it 
be not indicated by the thermometer, but perhaps principally to dimi- 
nution or suppression of the natural functions of the part. 

Pain. — Pain in an inflamed part is not in general continued; it is 
most acute during the systole of the left ventricle of the heart. It 
would seem, that the state of the blood influences the sensibility of 
the body in disease; if the mucous membrane of the bronchial tubes 
be extensively inflamed, the circulating blood will be principally 
venous, in which case little complaint is made of pain. 

Terminations of Inflammation. 

Inflammation, (says John Hunter,) cce/eris paribus, always pro- 
ceeds more favourably in strong than in weak constitutions; for, 
when there is much strength there is little irritability. In weak con- 
stitutions the operations of inflammation are backward, notwith- 
standing the part in which it is seated may possess, comparatively 
speaking, considerable vascular activity. 

This observation, like many others by the same author, however 
true with regard to surgical pathology, cannot be made to apply so 
universally in the practice of physic. We more frequently see acute 
diseases of internal organs gallop through a rapid course to a fatal 
termination, in robust, than in delicate individuals. Persons with 
delicate constitutions frequently sink, while labouring under internal 
inflammations, not because the diseased action has any peculiar 
tendency to terminate badly, but because the patients are too weak 
to bear the necessary remedies. 

In another place, Mr. Hunter remarks: — "It has been supposed 
that different species or varieties of inflammation arise from the dif- 
ference of the nature of the part inflamed ; but this is certainly not 
the case; for if it were, we should soon be made acquainted with all 
3 



£6 INFLAMMATION. 

the different inflammations in the same person at the same time, and 
even in the same wound ; for instance, in an amputation of a leg. 
&c It is the adhesive in them all, if the parts are brought to- 
gether ; it is the suppurative, if the parts are exposed." This obser- 
vation, no doubt, in some measure holds true in surgery; but it 
cannot be admitted in physic, as it is well known that inflammation 
terminates differently in different organs and tissues. 

The terminations of external inflammation are commonly styled 
" resolution ; suppuration ; ulceration ; and gangrene." The first is, 
of course, the most desirable ; and, fortunately for mankind, it is the 
most frequent. It is evinced by a diminution of pain and swelling 
— the fever gradually abates, pus does not form, nor does the struc- 
ture of the part suffer permanent injury. 

The second termination is that termed suppuration. After the 
inflammation has existed for a certain time, which varies much in 
different persons, pus begins to be secreted in the cellular substance, 
and either collects in one cavity, as in common phlegmon, or is 
diffused very generally over a whole limb, as in phlegmonous 
erysipelas. 

Ulceration is the third termination mentioned. 

The most dreaded termination, and fortunately the rarest, is the 
entire death of the parts affected, which are then said to be mortified 
or sphacelated. This condition is recognized by the sudden cessa- 
tion of pain ; the part, from being of a bright red colour, assumes a 
dusky hue; it crepitates from the extravasation of air in the cellular 
substance, vesications arise, a very peculiar odour is perceived, the 
pulse sinks, and every appearance announces speedy dissolution. 
Death, however, does not always follow mortification of external 
parts ; the dead are sometimes separated from the living parts, and 
are ultimately thrown off, the patient surviving the injury. 

It is now necessary to mention shortly the effects of inflammation 
in the following textures: 1. Skin. 2. Mucous membranes. 3. 
Cellular membrane. 4. Fibrous membranes. 5. Serous membranes. 
6. Inflammation of the solid viscera and glandular system. 

1. Inflammation of the skin. 

The effects of inflammation on this part of the body are very 
various: such as the formation of rashes, as in scarlatina, roseola, 
&c. ; pustules, as in small-pox, porrigo, &c. ; vesicles, as in chicken- 
pox, herpes, &c. ; papulae, as in measles, lichen, &c. ; scales, as in 
lepra; ulceration with loss of substance; and also gangrene. 

2. The effects of inflammation on mucous membraues, are, swell- 
ing and dryness ; effusion of mucus, or of matter of a puriform cha- 
racter — a mixture of the two, appropriately termed muco-purulent; 
of a serous fluid, and coagulable lymph. These different products 
of inflammation are sometimes colourless, at others yellow, and some- 
times red like currant jelly. The mucous membranes are likewise 
liable to softening, thickening, passive haemorrhage, ulceration, con- 
traction, sloughing, and tubercular formation. 

Some of these effects are common to the mucous lining of the air 
passages, alimentary canal, and urinary passages, as for instance, 
copious exudation of mucus, softening, thickening, and passive 



INFLAMMATION. 27 

haemorrhage. Others are not so ; tubercular formation, for instance, 
is more frequently met with in the alimentary canal. Ulceration is 
sometimes found in the air tubes, but more frequently in the stomach 
and bowels, particularly the latter, rarely in the bladder. Some 
parts of the mucous membrane of the same canal are more liable to 
inflammation and ulceration than others ; for instance, the termination 
of the ileum and the colon. Inflammation is more liable to terminate 
in the exudation of coagulable lymph in some parts than others; it 
is seen most frequently in the wind-pipe and rectum, although other 
parts are not altogether exempt. 

Considerable vascularity is not alone a certain proof of inflamma- 
tion having existed in the mucous membranes before death, because 
it may be found only in depending parts of the canals ; and conges- 
tions of this membrane may be occasioned by diseases of the heart 
and lungs, and by any other cause which obstructs the circulation of 
the blood. 

3. Inflammation of the cellular membrane terminates in effusion 
of blood, of lymph, of serum, of pus;— in induration and gangrene. 
Inflammation in this tissue is generally termed phlegmonous, and 
although the cellular membrane is so extensive and loose in its tex- 
ture, the disease tends to circumscribe itself by a sanatory process, 
and the effused matter to make its way to the surface of the body. 
Occasionally, though rarely, the inflammation has a tendency, from 
the first, to spread very extensively, from peculiar circumstances 
which have never been satisfactorily explained. To express this 
condition, several new-fashioned names have been invented ; the one 
most applicable, is, " diffuse cellular inflammation." Sometimes the 
death of a small portion of the cellular membrane takes place, then 
the affection is called carbuncle. 

4. Inflammation of fibrous membranes. This is the tissue which 
is generally supposed to be affected in gout and rheumatism ; the 
chief peculiarities are said to be, that it never terminates in suppu- 
ration, ulceration, or gangrene, and the functions of the brain are 
rarely disturbed during the course of the disease. It is said to ter- 
minate Bometimes by effusion of a gelatinous nature, or deposition of 
calcareous matter. This subject ought to be held as being open to 
future investigation ; it is by no means proved that the inflammation 
which attends gout or rheumatism is situated in such a texture. All 
the phenomena and the terminations of these diseases, tend to con- 
firm a suspicion, that it is seated in the extremities of nerves, more 
particularly when we reflect upon the sudden metastases. At all 
events, it is rather strange that so many authors should make the 
assertion, that inflammation of fibrous membranes never terminates 
in BUppuration and ulceration. What do they call the periosteum? 
Hut this question is too intricate and extensive, and some may think, 
too surgical, to be investigated in this work. 

5. Serous membranes in a state of health show few red vessels, 
and their surfaces exhale a thin serous fluid, which is just sufficient 

sdew them. When inflamed, red vessels are seen during life, 
an effusion takes place cither of serum or lymph, or of both. 
Sometimes the effusion is limpid, or turbid like whey: at other times 



28 INFLAMMATION. 

it looks like pus, and occasionally it is greenish, or resembles lees of 
wine; often large masses ofcoagulable lymph are discovered gluing 
the parts together. Adhesions between the different viscera of the 
thorax and of the abdomen seem to be effected by means of inter- 
vening portions of lymph, which subsequently become organized. 
The quantity of the effused matter is sometimes small, amounting 
only to a few ounces, at others there are several pounds. I have 
seen ten, twelve, and even twenty pounds in one side of the chest. 

A bloody effusion is sometimes found, more particularly in the 
abdomen. Ecchymosis not unfrequently takes place when the 
inflammatory action is very violent. There can be no doubt that 
tubercles form occasionally under a sub-acute and chronic inflam- 
mation of this class of membranes, more particularly in the perito- 
neum, pleura pulmonalis* and arachnoid coat. Emphysema also 
occurs in the cellular tissue immediately under the peritoneum. It has 
been proved by experiment, that the peritoneum, however vascular 
under acute inflammation during life, loses its red appearance even 
during the act of death. In chronic inflammation, it is sometimes 
found very red in colour, and thickened in texture. 

Much has been written during the last few years upon inflam- 
mation of the arachnoid, by which science has certainly been 
benefited ; but it appears to me that considerable misconception has 
taken place upon this subject. Although red vessels are rarely to be 
seen in the arachnoid, so rarely that in my whole life two undoubted 
instances only have presented themselves, yet no one who has paid 
attention to the situation of effusions of matter within the skull, will 
deny the existence of inflammation in that tissue. But it is compara- 
tively rare. In my examinations (and they have not been few in 
number) to ascertain this point, it has not occurred to me above six 
times to find effusions external to the arachnoid membrane. If, on 
examining the abdomen, we were to find no vascularity, and no 
adhesions, or effusions of serum or lymph, within the cavity of the 
peritoneum, but were to discover the effusion on the other side of 
the membrane, extra vasated for instance in the cellular tissue which 
connects the serous membrane to the adjacent parts, should we be 
entitled to say, from any thing we yet know, that this was a con- 
sequence of peritonitis. In the cases to which reference has been 
made, the effusion is between the arachnoid and the pia mater, 
which are united by fine cellular substance — the ivrong side, if it 
proceeded from diseased action in the former membrane, unless it 
has two serous surfaces, which is not maintained by any anatomist. 
There is not, perhaps, in the whole body, a more vascular mem- 
brane than the pia mater, and I cannot avoid concluding that 
the effusions, not only on the surface of the brain, but also in the 
ventricles, depend more on diseased action in this than the other 
membrane. 

Ulceration is also to be considered as an occasional, although rare, 
effect of inflammation in serous membranes. It has presented itself 
to me three or four times only. There are three splendid specimens 

* Tubercles are rarely seen in the pleura costalis. 



INFLAMMATION. £9 

of this change in my museum, two of ulceration of the pleura pul- 
monalis and costalis, the other, of the membranes on the surface of 
one of the hemispheres of the brain. 

Gangrene is one of the rarest results of inflammation of serous 
membranes, and it is to be doubted whether it ever occurs when the 
diseased action is confined to this tissue. 

6. Inflammation of the solid viscera and glandular system. The 
first circumstance generally perceived is the presence of an unusual 
quantity of blood in the affected organ. The first change in the 
structure of the viscus is softening. Hardening is owing, in general, 
to chronic inflammation. With respect to inflammation of the solid 
viscera, it is to be remarked, that if the liver be excepted, the termi- 
nation in the formation of abscess is rare. In the lungs, it is admitted 
by the best authorities to be rare ; I have seen it once only in the 
substance of the lungs. In the brain, it is probable that the peculiar 
change which has been denominated ramollissement, and the 
remains of old apoplectic effusions, together with tubercular degene- 
rations, have been often mistaken for abscesses. 

Tubercles are found in the substance of various organs, as in the 
liver, spleen, kidneys, lungs, and brain ; and there can be no doubt 
these are sometimes the result of inflammatory action, but no one 
is warranted in asserting that they are invariably so produced. I 
have frequently found in the lungs, and in the substance of the brain, 
depositions of a tubercular character, which were certainly not caused 
by inflammation, and which, in all probability, had been in existence 
for years without exciting inflammation. This statement refers to 
persons who were either killed by accident, who died suddenly 
without any previous complaint, or who were carried off by other 
diseases. One of the finest preparations in my collection, is the heart 
of a woman, extensively and deeply tuberculated, who died in a 
moment without a previous complaint, and no other lesion could be 
discovered. 

Lastly. Inflammation affecting glands, has an aptitude to ter- 
minate speedily in suppuration. Sometimes, however, they suppurate 
very slowly, and occasionally induration takes place. 

From this rapid sketch, it may be thought that the subject has 
not attracted a sufficient share of my attention, and that several points 
have been altogether overlooked ; such as the marked difference in 
the constitutional symptoms in inflammations affecting different 
tissues, and the general principles of treatment. The truth is, that 
the importance of these points is felt too deeply to allow me to treat 
of them in a general description— a description moreover, which 
ought necessarily to be very short. These subjects will be fully 
entered into in subsequent parts of the work. 



CHAPTER II. 



ON FEVER. 



HISTORY OF THE GENERAL DOCTRINES OF FEVER. 

The importance of the subjects which are to be discussed in this 
chapter is very great, from the frequent occurrence and often fatal 
termination of this class of disorders; and it will appear still more 
so, when we reflect on the great extent of our dominions abroad, 
where, it is believed, febrile diseases carry off more than four-fifths 
of those who die. 

If a person, after shivering, feels hot, restless, and thirsty, has a 
quick pulse, and complains of languor, he is said to have a fever. 

Galen's notion of fever appears to have been that an extreme 
degree of heat is formed in the heart, and from thence extends itself 
to the rest of the body. It is one of the oldest notions in medicine, 
that fevers are produced by a concoction of something pernicious to 
the system, which is expelled by a critical effort of nature, as, for 
instance, by frequent and copious evacuations from the bowels, free 
perspiration, &c. This is the view of fever taken by the humoral 
pathologists. 

According to Boerhaave, fevers arise from the same pathological 
causes as inflammations — thus ascribing them to viscidity of the 
blood, error loci and an acrimonious state of the fluids. He con- 
ceived that the cold stage of fever was produced by the error loci, 
and all that followed was to be regarded as natural consequences. 
As has been mentioned in treating of inflammation, the first idea 
which appears to have been given to the world, of the influence of 
the nervous system in the production of fever, originated with Stahl, 
and it was improved upon by his colleague, Hoffman. They sup- 
posed that fever consisted in a tonic spasm, produced on the extremi- 
ties of the nerves by a deficiency of action in the brain. They also 
adopted the humoral pathology ; but insisted, that the sanative 
process was impeded by the spasm at the extremities of the nerves, 
thereby preventing the disease from being thrown off; and it 
appears to have been their opinion, that it was this resistance which 
produced the constitutional commotion which attends fevers. 

According to Cullen, the human body is composed of certain or- 
gans, whose actions are regulated according to laws peculiar to ani- 
mal life, and superintended by a mobile and conservative energy, 
which is situated in the brain, acting wisely but necessarily for the 
general health, preventing mischief and repairing injuries, by a pre- 



ON FEVER. 31 

established relation between the changes produced, and the motions 
required for the restoration of health, which actions are performed by 
the nerves. According to him, the muscular filaments are merely the 
extremeties of nerves. He supposed that fever is produced by a 
collapse or diminution of the energy of the brain, in consequence of 
the influence of contagion, miasm, cold and fear acting as sedatives. 
This diminished energy produces a universal debility, and causes a 
spasm of the extreme vessels, and in this spasm the cold fit is sup- 
posed to consist. In fact, that fever is nothing more than diminished 
energy of the brain, and spasm of the capillaries. He conceived that 
the debility proves a stimulus to the circulating system, exciting in- 
creased action of the heart and arteries, which continues till it restores 
the energy of the brain; by removing the cause of the spasm of the 
extreme vessels, relaxation takes place, and health is restored by a 
copious sweat, or discharge of some of the other excretions. He di- 
vided the whole phenomena into three stages ; first, the stage of 
diminished energy of the brain, and consequent debility : secondly, 
that of spasm of the extreme vessels ; and thirdly, all that follows 
till the commencement of the sweating stage. Perceiving his doc- 
trines to be exceedingly weak, Cullen sought support from certain 
powers which are supposed to be inherent in the constitution, which 
enable it to resist and throw off disease, commonly called the vis 
medicatrix natarss. But it is important that he should here speak 
for himself. " Upon the whole, our doctrine of fever is explicitly 
this : — The remote causes, are certain sedative powers applied to the 
nervous system, which diminishing the energy of the brain, thereby 
produce a debility in the whole of the functions, and particularly in 
the action of the extreme vessels. Such, however, is, at the same 
time, the nature of the animal economy, that this debility proves an 
indirect stimulus to the sanguiferous system; whence, by the inter- 
vention of the cold stage, and spasm connected with it, the action of 
the heart and large arteries is increased, and continues so, till it has 
had the effect of restoring the energy of the brain, of extending this 
energy to the extreme vessels, of restoring their action, and thereby 
especially overcoming the spasm affecting them ; upon the removal 
01 which, the excretion of sweat, and other marks of the relaxation 
of excretories, take place. This doctrine will, as I suppose, serve to 
explain, not only the nature of fever in general, but also the various 
cases of it which occur." 

It is remarkable that Cullen, who has insisted with so much per- 
tinacity on spasm of the extreme vessels being a principal part of 
fever, should so completely have forgotten himself, as to assert that 
atony, which is the very reverse of spasm, is also a principal cir- 
cumstance in the pathology of fever. But he shall again speak for 
himself. "From the whole we have now said on the subject, I think 
it is sufficiently probable, that the symptoms of anorexia, nausea, and 
vomiting, depend upon, and are a proof of, an atony subsisting in the 
extreme vessels on the surface of the body, and that this atony, there- 
fore, now ascertained as a matter of fact, may be considered as a 
principal circumstance in the proximate cause of fever." " This atony 
we suppose to depend upon a diminution of the energy of the brain ; 



32 ON FEVER. 

and that this takes place in fevers we conclude, not only from the de- 
bility prevailing in so many functions of the body mentioned above, 
but particularly from symptoms which are peculiar to the brain 
itself." 

The meaning of « spasm of the extreme vessels," is morbid con- 
traction ; that of atony of the extreme vessels, is a defect of muscular 
contraction. Can a morbid contraction, and a morbid relaxation, co- 
exist in the same vessels at the same time ? This contradiction 
appears to me to be quite unparalleled — it always surprised and dis- 
appointed me in the investigation of this subject ; and it is astonishing 
that doctrines founded upon such statements should still be maintained. 
In the present improved state of pathology, it is almost unnecessary 
to enter into proof, for the purpose of showing the error of attributing 
to spasm of the extreme vessels any part of the pathology of fever ; 
but it may be mentioned that, in some fevers, copious perspiration 
takes place through their whole course; and, even in the cold stage 
of intermittent, the surface is occasionally covered with moisture.* 

It appears that Cullen and others always confounded debility or 
actual weakness, with oppression from obstructed action. The de- 
bility which depends upon obstructed action is very different from 
that produced by starvation, a protracted disease, or great loss of 
blood, &c. ; it is mere oppression occasioned by the loss of balance 
between the arterial and venous systems: and the proof consists in 
the well known fact, that upon the restoration of that balance, the 
overpowering sensations of weakness vanish, even when brought 
about by blood-letting, which is a remedy directly debilitating. If 
debility formed such a regular and indispensable part of fever, as the 
Cullenians assert, three circumstances ought to follow as necessary 
consequences. Is/, Weakness, produced in so many different, ways, 
should invariably excite fever. 2d, Once a fever is lighted up in the 
system, it ought to be impossible to extinguish it, and particularly by 
any antiphlogistic means; and, 3d, The longer such an action con- 
tinues, the greater will be the debility, and therefore the febrile symp- 
toms ought to become more and more intractable. 

The term "diminished energy of the brain," being a principal 
part of the foundation of Cullen's doctrines, cannot be allowed to 
pass without notice. It is one of those vague terms too often used by 
him to express a great deal more than we actually know, but which 
in reality explains nothing. It is one of those expressions which 
satisfies the youthful mind, without affording instruction or exciting 
inquiry. What is the natural energy of the brain ? How is it pro- 
pagated ? It would be very satisfactory if the living advocates of 
this system would inform us, at what period of the disease the en- 
ergy of the brain exists in its most perfect state, and greatest strength. 
Is it at the period of attack, or at its termination ? It appears to 
me to be most unphilosophical to treat of diminished energy of the 
brain as a principal part of any disease, because it has no precise 

* I have written more fully upon this subject, to show the great absurdity of the 
doctrines of Cullen, in a paper in the Medico-Chirurgical Review for January, 



ON FEVER. S3 

meaning. It can be of no use in explaining the nature and seat of 
fever, and of still less service in directing the plan of treatment. 

Cullen too hastily rejected the humoral pathology, and. seems un- 
fortunately to have almost entirely disregarded the effects produced 
by outward causes, and inward irritations, in producing irregular de- 
termination of blood, and local engorgements ; which, I shall here- 
after attempt to show, are the great agents in exciting diseases, and 
especially fevers. It may be noticed in this place, that Dr. Mason 
Good, in his large and laborious work, advocates the truth of the 
chief parts of the Cullenian doctrines. 

According to Dr. Brown, man is made of organized materials, en- 
dowed with a principle of excitability or predisposition to excitement, 
by means of a great variety of stimuli, some of" which are constantly 
acting upon the machine. This excitability, in point of fact, is 
nothing more than the nervous energy of Dr. Cullen ; it is the prin- 
ciple of life, or life itself. It is, according to Brown, constantly vary- 
ing in its accumulation and exhaustion; yet it differs somewhat from 
the nervous energy of Cullen, which is influenced by something 
unconnected with the matter of organization, and which he terms 
"via medicatrix naturae"— whereas Brown's excitability is passively 
exposed to the effects of such stimuli as it may chance to meet with, 
and yields to their influence. He divided all diseases into two classes: 
the first, caused by accumulated excitability, and marked by direct 
debility; to this class he gave the name of Sthenic. The second, 
produced by exhausted excitability, and marked by indirect debility; 
this class he termed Asthenic. And his treatment is as simple as the 
arrangement, viz. in the first case, to reduce the excitability by anti- 
phlogistic means: and in the second, to increase the excitability by 
an opposite treatment. It can scarcely be believed, that an author 
who acquired so much reputation, could have been guilty of pub- 
lishing such nonsense on a point of such vital importance, as the 
following: — "In order both to prevent and cure diseases, we must 
always use the indication proposed, and stimulate or debilitate ; never 
wait or trust to the supposed powers of nature, which have no real 
existence."* It is surprising, considering that his works abound 
with absurdities equally glaring, that Dr. Brown should have made 
any converts; and it is not very creditable to the age in which he 
lived, that it should be told he had numerous followers— but they soon 
began to fall off; and it is curious, that in proportion as they declined 
in number at home, they increased abroad, and are at this very mo- 
ment, with some modifications, in considerable force in Italy, notwith- 
standing the exposure of the fallacies of the system made by Rasori. 

Dr. Darwin improved the Brunonian doctrines, in so far as lie 
makes Ihe brain the common fountain, from which every other organ 
is supplied with sensorial fluid. He regards the sensorial fluid as a 
mere secretion, capable of being exhausted in four different ways, 
through the agency of four separate faculties which he ascribes to it. 

1st, The faculty of Irritability y exhausted by internal stimuli, 
affecting simple irritable fibres. 

t Elements of ihe Piacticc of Physic, vol. i. p. 81. 



34 ON FEVER. 

2d, Of Sensibility, exhausted by stimuli affecting the fibres of the 
organs of sense. 

3d, Of Voluntarily, exhausted by stimuli affecting the fibres of 
those organs which act in obedience to the will. 

4th, and lastly, of Jlssociability ; exhausted by stimuli affecting 
organs associated in their actions by sympathy or long habit. 

By each of these means, Darwin supposes the sensorial power be- 
comes evacuated, as by food and rest it becomes replenished, often 
indeed with an accumulation or surplus stock of power. He there- 
fore considers the occasional causes of fever, (whatever they may be,) 
as inducing a torpor of the extreme arteries, and the subsequent heat, 
as an inordinate action of the sensorial power hereby accumulated to 
excess. 

This subject might be pursued much farther, but more minute 
detail does not consist with the plan of this work, particularly as the 
individuals whose names have been mentioned have bewildered 
themselves with theories, have substituted mere conjectures for facts 
to which they have given appellations, have replaced one mystery by 
adding another quite as inexplicable, and seem to have considered 
the subject without reference to morbid dissection, or to the habits 
and modes of living in different societies and climates. 

I still have to mention the doctrines of more modern pathologists, 
which are alleged to be founded on morbid dissection. Some of these 
contend that fever (or as they term it, the proximate cause of fever) 
depends upon inflammation of a particular organ. Thus it has been 
attributed to inflammation of the brain— of the liver — of the diges- 
tive organs generally — of the mucous membrane of the stomach and 
intestines particularly — and of the arteries and veins. 

It is necessary to caution young practitioners, and more particu- 
larly those commencing the study of medicine, against implicitly 
receiving the arbitrary doctrines of fever which divide the profession 
in the present day, viz. that fever is invariably produced by inflam- 
mation of one viscus, or set of viscera. 

Dr. Clutterbuck, a physician of reputation in London, has most 
ingeniously attempted to prove that fever depends upon some degree 
of inflammation of the brain. In reviewing the merits of his system, 
it must be kept in view, that he practises in the greatest commercial 
city in the universe, among a people whose minds generally speaking 
are more actively employed then their bodies, who are exposed to 
intense anxieties, occasioned by extensive speculations and reverses 
of fortune, who are either in a state of considerable mental excite- 
ment or depression. If to these considerations we add the effects of 
heavy meals and sedentary habits, impeding the functions of the 
stomach and the bowels, it will be seen, that there may be considera- 
ble foundation for the opinions this gentleman has been led to advance. 
But I object to the arbitrary application of his doctrines. 

Broussais, to whom the profession stands greatly indebted, and 
whose merits, like those of many others, have been more justly esti- 
mated abroad than at home, asserts that all fevers may be referred 
to gastro-enteritis, simple or complicated. In France it is no wonder 
that Broussais should so frequently find the mucous membrane of the 



ON FEVER. 55 

stomach and intestines altered both in appearance and structure, if 
the habits and modes of living of the people are recollected. The 
stewed meats, salads, oils and sweets, consumed by Frenchmen 
among the higher ranks, together with the hard beer and acid wines 
which they drink, and the unwholesome food eaten by the lower 
ranks, all tend to produce irritation in the digestive organs. Sooner 
or later, these irritating matters produce increased vascularity, which 
must frequently terminate in inflammation and ulceration. It is easy, 
therefore, to account for the doctrines of Broussais, and for the tone 
in which he supports them; and while I allow him every merit and 
commendation which is so justly his due, I cannot help objecting to 
the arbitrary manner in which he wishes to apply them. 

There are other individuals of the present day, who assert that 
fevers have never any connection with inflammation, except in as 
much as they occasionally excite it in their progress ; and in alluding 
to the appearances so frequently found on dissection, they trium- 
phantly but erroneously allege, that such appearances are the effect, 
and not the cause of the disease. Change of structure is certainly 
only a consequence of previous disordered action, but in fever it is 
not always difficult to trace the progress of the local disease, from the 
beginning of the disordered action till the structure of the part is in- 
jured. They are many persons who imagine that inflammation can- 
not exist in any organ or tissue of the body, in any degree, without 
a strong and quick pulse, thirst, restlessness, and considerable pain. 
Fatal error ! 

The war of opinion in France respecting the pathology of fever, is 
at present too great to entitle us to expect candour from all the com- 
batants. Much talent is already in the field, and when the stage of 
excitement is over, the science of medicine will probably be found to 
have gained very considerably. Some are ready to assert the uni- 
versal truth of the new doctrine at the point of the sword, while 
others as strenuously, and apparently as sincerely, deny them. New 
advocates are daily coming forward on each side ; and while we may 
express our admiration of the zeal, ability, and assiduity, displayed 
by so many individuals, still I cannot avoid stating my conviction, 
that their .services would be more useful to suffering humanity, if 
many of the authors thought more, and wrote less. From this 
reflection, I would beg to exclude the truly valuable works of Brous- 
sais, Alld rat, Laennec, Boisseau, Bailly, and' many others; but even 
with respect to these, if that of M. Bailly is excepted, it is melancholy 
to reflect upon the little practical benefit they have themselves de- 
rived from pathological investigations. They have filled large vol- 
umes with cases and dissections, but their practice is too expectant 
on most occasions, and generally weak and vacillating. Having 
already expressed myself candidly respecting the errors of authors of 
our own country, I may be permitted to do the same with respect to 
those of the French school; and I must farther add an expression of 
surprise at the little acquaintance with British medical literature, 
winch even their best writers display. Frequent opportunities will 
occur, in the course of this work, to quote, with benefit to my readers, 
many important facts from French works; but in this doctrinal his- 



36 [PHYSIOLOGICAL DOCTRINES] 

tory, it would be of little service in general, and occasionally would 
make "darkness visible." 



[Physiological Doctrines.'] 

[Broussais, whose name has excited so much attention in the 
medical annals of this country, and whose doctrines have created no 
little disputation, is the well-known author of what is entitled the 
Physiological System of Medicine. We shall not stop to inquire 
whether this system is with propriety styled a physiological one, and 
based upon correct views of physiology ; or, on the contrary, 
whether it rests upon false conceptions of vital phenomena: because 
it involves a question which can only be decided by the acquisition 
of a greater number of facts than we at present possess, derived 
from an accurate and well directed observation of the phenomena of 
health and disease. Our object, therefore, will merely be to present 
to the reader a few of the general principles of this system, together 
with the mode of reasoning by which they have been arrived at, 
and afterwards to give a concise view of the droctrine of fever, as 
founded upon these general principles. This then will be our 
apology for the length of the following preliminary observations. 

The animal frame consists of a number of organs, and these 
organs of different tissues, which modify their relative importance. 
The tissues are composed of solid and fluid elements, acting and 
reacting mutually upon each other by virtue of their molecular 
forces ; the movements thus excited constitute organic action. The 
organs are formed to carry on, in a natural state, certain operations 
or functions, necessary in themselves, and conducive to specific 
purposes. They may be' said to have an isolated existence when 
considered merely as to their dissimilar modes of operation ; but they 
are, when regarded as portions of an elaborate and intricate machine, 
so intimately connected that each one, to a certain extent, is depend- 
ent upon the other ; thus constituting a beautiful and complex whole, 
made up of equally complex parts. 

The several organs are connected with each other by a subser- 
viency of function ; that is, the integrity of each one cannot be 
individually maintained without the assistance of the others; while at 
the same time there exists a sympathetic tie which pervades them all. 
For example, the brain and spinal marrow together with the gan- 
glionic system, possess the command of nervous influence, which is 
brought to bear upon the functions of the heart ; but it cannot exert 
this influence unless the latter keeps up its regular supply of arterial 
blood. The stomach, in like manner, cannot secrete the gastric 
liquor unless it is supplied with blood ; nor can the heart furnish a 
supply unless the function of digestion is sufficiently active to elabo- 
rate the materials of nutrition. This arrangement holds with regard 
to all the organs, constituting a circle of dependencies, any one of 
which being disturbed, the whole is affected. The other species of 
connection, though less intimate, is still of great importance : it is 
the sympathy which exists among them, causing all to be more or 
less disordered by the derangements of a single one, and leading to 



[PHYSIOLOGICAL DOCTRINES.] 37 

remote or present injurious effects, in proportion to the degree of dis- 
turbance. This connection preserves harmony of action in organs 
which are not contiguous, and sustains their relative tone and force. 
For the purpose of elucidation, we need only cite the relation which 
exists between the brain and the stomach, the stomach and. skin, &c. 

The organs have been stated to consist of tissues which differ in 
structure, uses and modes of life. They are combined in variable 
proportions, so as to adapt the organ to the purposes for which it 
was designed. To illustrate this, in the stomach are found four 
tissues, externally the serous, to enable it to glide with facility upon 
the neighbouring parts; next the muscular, to propel its contents; 
then the cellular, as a connecting medium; and finally, the mucous, 
to assimilate the food, and prepare it for its conversion into blood. 
In the construction of the heart are found three tissues — the serous, 
fibrous, and muscular, they being all required to perform its func- 
tions. The organs are divided into two great classes — one in- 
cluding those which are necessary to the maintenance of the indi- 
vidual ; the other, those which are in connection with the exterior 
world. 

-> Life is defined to be organism in action; it is supposed to be a 
state of activity in the organs maintained by the operation of stimuli. 
In order that these stimuli should act, a certain degree of suscep- 
tibility to their impression in the tissues and organs is requisite, 
which lias been designated by the term excitability; and the state 
produced is called excitation; so that an organ in the full natural 
enjoyment of its functions, is said to be in a state of excitation. As 
far as we can judge, excitability is not the same in all the organs 
and tissues, since there is so vast a disparity of construction : but in 
each organ and tissue it remains unchanged as to nature, modified 
only by increase or diminution, and requiring an appropriate stimulus 
to bring it into action. Excitability is greater during youth, and 
diminishes in old age ; hence it cannot be prolonged indefinitely. 

The stimuli affecting our organs are the physical influences by 
which we are surrounded — as caloric, light, air, food, &c., which 
when not operating in excess, are fully capable of maintaining life; 
but when these stimuli are present in excess, or acquire more than 
their usual activity, an injurious impression is then produced, the 
excitability is increased, and super-excitability is the consequence: 
and as this is called irritability, the disordered excitation is termed 
irritation. The contrary of these, determined by opposite causes, 
and characterized by a depression of the excitability, and attendant 
inaction or torpor, is said to be a state of ab-irrilalion. According 
to this view it will be perceived, that we have two conditions; a 
physiological one, where life is maintained without excess or diminu- 
tion ■ a pathological one, where life is carried beyond the natural 
standard, or falls short of its proper activity. 

Excitability must he a vital property, since it is not possessed by 
inorganic matter. 

The influence of any one organ upon the rest of the economy, is 
m proportion to its importance in the preservation of the individual. 
After birth, the brain, spinal marrow, heart and lungs appear of 
4 



38 [PHYSIOLOGICAL DOCTRINES ] 

greater necessity than the stomach, bowels, and other viscera ; 
because, if the former are seriously injured, death must almost 
immediately ensue; but the stomach, from the fact of its supplying 
the materials of nutrition, without which all the organs must perish, 
rises in the scale of importance ; and in this light all others are but 
auxiliary to it. 

In a state of health it is rare to witness two organs at the same 
time excited in the same degree ; that is, by a stimulant acting upon 
one and sympathetically transmitted to the other; since we observe, 
for instance, when the brain is in action the stomach is quiescent, 
and vice versa; but when several organs are roused at the same 
time by their appropriate stimuli, they react strongly upon one 
another, and excitement is generalized as much as possible. 

The degree of excitability predominates in certain organs according 
to the age, sex and constitution. The preponderance of vital action 
in any one organ which influences more or less the whole of the 
organism, is the foundation of temperaments. Individuals compared 
with each other present remarkable differences of excitability ; this 
constitutes idiosyncrasy. 

When the functions of an organ are impaired, it is diseased. All 
disease consists in the alteration of the organic actions of one or more 
organs, leading to irregular exercise of the functions. Derangement 
of organic action in deep-seated parts, can commonly be appreciated 
only through the medium of the consequent functional disturbance, 
which never exists independently of the former. Symptoms then 
are nothing more than manifestations of disordered organic action. 

Irritation is defined to be the augmentation of the organic action 
of a tissue beyond the limits compatible with the free exercise of its 
functions. The following are some of the laws which it obeys: 

1. Irritation is always primitively local ; it commences in some 
one organ. The stimulating impressions are mostly made upon the 
external surface, or those in relation with the exterior world. The 
idea of irritation being brought about without the operation of stimu- 
lants is erroneous ; hence there is no disease strictly spontaneous ; all 
are referable to some cause. Irritation can never exist in all parts 
of the body at the same time, but can occupy by irradiation at once, 
one, two, or three organs. The maxim of Hippocrates, however, is 
founded in nature. " Duobus doloribus simul existentibus, vehe- 
mentior obscurat alteram." It is due to the impress of stimulating 
agents, to the transmission of this effect from organ to organ by the 
sympathies, to the momentary abstraction of stimulus from an organ 
where the excitability is great— to the removal of excitement from 
an important organ, so that surexcitation is caused in another. In 
this case there is a positive sedative impression, diminishing the 
organic movements; as, for example, the effect of cold applied to the 
skin, which it debilitates while it excites the internal organs; so also 
hunger, &c. Hence, directly or indirectly, irritation is^first engen- 
dered in a single organ. 

2. Irritation may exist in an organ, and yet its presence not be 
announced by any symptoms whatever, until it has accomplished 



[PHYSIOLOGICAL DOCTRINES.] 39 

the destruction of the individual, and examination after death re- 
veals its seat and nature. 

3. Irritation deranges and weakens the functional actions of a 
tissue or organ in which it is located. The reverse, at first sight, 
would appear to be the case, because irritation is stated to augment 
the organic movements. The exercise of a function cannot be 
regular, however, when the organization of the tissue which exe- 
cutes it is impaired; hence irritation, by inducing derangement, is 
followed by embarrassment of function; the vital movements are 
carried beyond their normal standard, and, as it were, clogged by 
excess of energy. Thus an inflamed stomach will digest as imper- 
fectly as one weakened by atonic influences; a single exception to 
this law exists — it is when nutritive irritation has increased the 
growth and power of an organ. 

4. Irritation is susceptibfe of various degrees of intensity, which 
are evinced according to the tissues which it occupies, and the in- 
dividual. As tissues are anatomically different, they are not all 
equally susceptible of irritation, and there is a similar disparity 
among individuals. The extent which it occupies, the amount of 
accompanying uneasiness, the tumefaction of the part, and the energy 
with which it reacts upon other organs, will point out its intensity, 
which is in proportion to the number of these attendant circum- 
stances. Hence irritation is acute, when these are considerable: 
chronic, when less so, and the course which it runs is not rapid: con- 
tinuous, when it pursues an uniform course from origin to termina- 
tion ; and intermittent, when it appears only at intervals. 

The intensity of irritation depends upon two circumstances; the 
force of the stimulating impression, and the irritability of the tissue. 
If the causes are light, and the tissues little irritable, the irritation 
will be proportionably small; but where the opposite conditions 
exist, the effect is modified accordingly. Should the impress of 
stimulation be energetic, and the tissue possess little irritability, the 
effect may be light ; but should the cause be light and the tissue very 
irritable, a high degree of irritation will be the consequence. A con- 
tinual form is that under which irritation is most generally mani- 
fested. The reason is plain ; an exciting agent acts forcibly upon a 
tissue; it exalts the irritability and produces an irritated condition. 
Although the cause may cease to act, yet the effect will be persistent, 
lince the organic forces have been excited, and it requires some time 
to hung them back to their normal state. But an intermittent form 
may be presented. It is owing to causes which act at intervals. It 
takes place in organs whose functions are not continued, but peri- 
odic il; or, it may occur from habit. 

Irritation is susceptible of six principal modifications; in other 
words, the local phenomena which accompany irritation show them- 
selves under six different aspects easily recognized. They arc all 
attributable to the s ime law, viz., "ubi stimulus ibi affluxue." The 
first phenomenon is an afflux of fluids to the irritated point, pro- 
voking the conditions afterwards mentioned. If this simple mode 
of explanation is not admitted, there would he as many hypothetical 
- as there are forms of local derangement; there would have to 



40 [PHYSIOLOGICAL DOCTRINES.] 

be a specific power for the production of each; and whether it is 
called a vis a tergo or any thing else, one would be necessary to 
excite inflammation, another serous congestion, a third lymphatic 
accumulations, and so on; but all these are obviated by reference 
to the idea of an irritation everywhere the same in character, but 
modified by tissue and other organic conditions. In the greater 
number of cases the part becomes painful, hot, swollen and red, and 
there is more blood in the capillaries than necessary : — this consti- 
tutes inflammatory irritation. When the tissue is hot, painful, and 
tumefied, allowing blood to escape from its surface, hxmorrhugic 
irritation is said to be present. If there is little or no pain, little in- 
crease of warmth, and the tissue affected is not reddened, but tume- 
fies, takes on a homogeneous whitish appearance, as if white fluids 
alone had entered the capillaries in excess, it is termed lymphatic 
irritation, or sub-inflammation. If the tissue is simply painful, 
there being no manifestation of change in colour, or increase of 
volume, nervous irritation is the designation by which it is known. 
In this it is supposed to reside entirely in the nervous filaments. The 
organic movements may be increased scarcely beyond the physiolo- 
gical action, but by long continuance may invigorate the nutrition 
of a tissue; this is the nutritive irritation of the physiological school. 
And finally, should it be located in a tissue whose office is secretion, 
there may be an augmented flow of its peculiar product : and this 
forms secretory irritation. In all the structures in which these forms 
of irritation occur, with the exception of the nervous, it is requisite 
that an abundance of vessels should exist. If, however, a purely 
nervous excitement in a part be augmented, and the pain be 
greatly aggravated, an increased amount of fluid will be directed to 
it, and tumefaction ensue. Morbid congestion and increased nutri- 
tive action, leading to disorganization, are, therefore, in ail cases, the 
effects of a sufficiently powerful irritation. 

In the foregoing account of irritation and its consequences, it is 
supposed that one organ alone is implicated; a succession of them, 
however, may be included within the cirele of diseased action, and 
this is effected by means of the sympathies. Irritation rarely con- 
fines itself to the part originally affected, but is irradiated from this 
to others with a rapidity and energy which vary according to the 
irritability of the individual, the intensity of the irritation in the 
organ primarily affected, the importance of this one in the economy, 
its irritability, and the number and degree of its relations with others. 
Diseased sympathetic action is communicated in the same way, and 
by the same channels as physiological sympathy; and consequently, 
the organs which are most closely connected in a state of health, will 
be proportionably influenced when irritation is kindled up. Its 
transfer will be found strictly to adhere to this law. Thus the sto- 
mach, being connected with the brain and heart by the most intimate 
union, will convey to them its morbid impressions, and cause them 
to assume a portion of its irritation. 

To exemplify the truth of these declarations, the following facts 
are brought forward. In infants, females, and those of a naturally 
excitable constitution, the lightest degree of irritation in an organ 



[PHYSIOLOGICAL DOCTRINES.] 4! 

will excite a train of sympathies which extends through the whole 
series, and becomes more or less general; while in old people, and 
those whose sympathetic relations are diminished and weakened, 
an organ will sometimes be seriously affected, and even destroyed, 
without reacting upon any other. Sympathies are more influenced 
by the intensity than by the mere extent of irritation ; and the reason 
is, that the number of sympathetic connections which an organ pos- 
sesses are limited, and an intense circumscribed irritation may excite 
the whole of them to their full extent, while a greater local diffusion 
of it can do no more than bring them all equally into exercise; so 
that the more intense this may be, the more decided will be the dis- 
turbance in other organs, and the contrary. A secondary may 
exceed and mask, to a certain extent, a primary irritation, and, as it 
were, become the predominant one. Hence, false inferences may be 
drawn from the symptoms as to the commencing seat of disease; the 
secondary irritation so far exceeding the primary that the latter is 
overlooked; when, if care be taken to ascertain the first symptoms 
which manifested themselves, they would be found to appertain to a 
remote organ. In this manner, also, the secondary irritation may 
continue after all traces of the primary affection have vanished. An 
apparent exception to this law may exist where the primary irrita- 
tion is so intense in an influential organ, as to concentrate in it all 
the irritative action which, under ordinary circumstances, would be 
diffused through the organs generally. 

If the irritability of an organ is great, the more easily will its sym- 
pathies be excited. 

Of all the organs, the nervous system possesses the greatest in- 
fluence with regard to the sympathies; next are the stomach and 
intestines; then the heart, skin, lungs, &c. Sympathetic action among 
the organs is reciprocal; those which receive the greatest number of 
secondary impressions, produce the greatest number when they 
themselves are first the scat of irritation. 

Sympathetic irritation is similar in character to the primitive. 
Morbid sympathies are of two kinds; the first is manifested by 
organic phenomena, as congestions; augmented, diminished, or 
morbid secretions, &c. ; and these are termed the sympathies of 
organic life. The second is evinced by pains, spasms of the volun- 
tary muscles, convulsions, &.c, which are the sympathies of relation. 
If the irritation is sufficiently intense in the organ secondarily affected, 
the character will be inflammatory ; when it emanates from a pri- 
mary inflammation, a hemorrhagic action will ensue, as a consc- 
quence of hemorrhage; and so of the others. Diathesis, then, is 
nothing more than the tendency to the reproduction, in other organs, 
of a condition similar to the one which exists in the organ first 
affected; and, therefore, the diatheses are thus particularized; the 
inflammatory diathesis, the hemorrhagic <liu/hrsis, the nervous 
diathesis, the sub-inflammatory diathesis, the diatheses of secretory 
and nutritive irritation. This law is strictly maintained as long 
as the irritation is conflned to a tissue similar to the one in which it 
primarily occurred ; so that hemorrhagic or nervous irritations in 
mucous membranes, will sympathetically produce the same affection 

4* 



42 [PHYSIOLOGICAL DOCTRINES.] 

in a similar tissue; and sub-inflammation of the lymphatic ganglions 
will affect, in an analogous manner, the lymphatic system, and so 
on. If, however, the sympathetic or secondary irritation is not re- 
peated in the particular tissue in which it first originated, but in some 
other, the effect will be modified by the character of the tissue second- 
arily affected ; if, for instance, inflammation of the mucous membrane 
be sympathetically communicated to the lymphatics, a sub-inflam- 
matory condition will ensue. Some exceptions, however, are ad- 
mitted with regard to irritations transmitted to various points of the 
same organic system ; for haemorrhage, for example, may be the result 
of a transmitted inflammation, and the reverse. 

Sympathetic irritation is transmitted by means of the nervous cords, 
with or without the intervention of the brain. Both systems of 
nerves are conducive to this end; the cerebro-spinal being the agents 
of the sympathies between the organs of relation; the ganglionic, of 
the organic sympathies; and the intimate connection betweeti these 
two systems explains the attendant phenomena when both are in- 
volved. 

The danger of death by acute disease, depends upon the intensity 
of cerebral disturbance, whether primary or secondary; so important 
is the immediate influence of the brain in the preservation of life. 
Other organs, by undergoing morbid changes, lead to this result at a 
later period ; but when such changes are considerable, they react 
upon the brain, and transfer the risk of dissolution to derangements 
of that organ. 

If, in acute disease, the skin, or any secretory organ, assume a trans- 
mitted irritation more intense than the original one, and, producing a 
free discharge of its peculiar secretion, a revulsive effect is brought 
about, the affection is said to disappear by crisis. There are crises 
which, instead of conducing to a favourable result, and leading to 
restored health, are productive of more alarming and threatening 
symptoms. It is said, in the language of those who have not scru- 
tinized the subject, that nature has attempted a cure, but failed, and 
has sunk under the effort ; such is the case of retrocedent irritation in 
secretory organs, as checked perspiration, diarrhoea, &c. These are 
called false crises, and are attributable to the sudden attack of some 
very important internal organ necessary to life. The termination of 
irritation is more or less rapid according to the tissue involved, the 
cause producing it, or the character of the sympathies which it has 
excited. 

The state of irritation under which an organ or tissue labours, pro- 
ductive of increased vital movements, is called hyperemia. 

It will be necessary to devote a few words to snb-irritation or 
ansemia. In this case, life in an organ is below the healthy standard, 
the organic movements are depressed, and debility of its functions is 
the consequence. It is the very opposite of irritation ; hence a short 
account of its causes and laws will be sufficient for our purpose. An 
anaemic condition of an organ is rarely primitive, but is rather the 
result of irritation located in some other viscus. The following ex- 
planation will convey a direct idea of what is understood to be its 
nature. Those organs which are not themselves irritated, and do 



[PHYSIOLOGICAL DOCTRINES.] 43 

not receive transmitted irritation, may nevertheless become greatly- 
enfeebled; because organic activity is concentrated in others, and 
withdrawn from them. If this were not the case, the first law of 
irritation would be incorrect; for then there might be a repetition of it 
in all the organs, and universal excitement be present, which is an 
impossibility. For example, when the heart and vascular system 
are stimulated to increased activity by the existence of visceral irrita- 
tions, muscular power diminishes; when the locomotive apparatus is 
violently excited or convulsed, nutrition languishes, the secretions are 
impaired, the heart circulates blood irregularly, the brain is weakened 
in its intellectual operations. In maniacs, where the brain is in a 
state of high activity, the heart and muscular system may have ac- 
quired more energy, but the secretions are interrupted, the intestines 
rendered dry and insusceptible to stimulation, nutrition is suspended 
in them, and the sero-ceilular tissues are in a state very opposite to 
that of inflammation. By this view of things the idea of diathesis, 
as meaning general habit, is refuted. 

Anaemia may be produced in three ways: 1st, By the abstraction 
of all stimulation from an organ: 2d, By diminishing the stimulating 
influence which one organ receives from another by sympathy : 3d, 
By the intense excitement of some important organ concentrating 
activity in itself. 

An anaemic state is marked by the following appearances and symp- 
toms— Paleness, flaccidity, coldness and insensibility, diminution or 
total depravation of functions. 

Sur-excitalion and intense local morbid congestion, are compati- 
ble with the general diminution of the forces. This is one of the 
most important truths of the physiological doctrine, and ignorance of 
it lias led to doubt, uncertainty, and erroneous practice. Diseases 
essentially active in consequence of mistaken ideas of their nature, 
have been treated for those of opposite character. It is difficult to 
convince some persons that when exhaustion and marasmus are the 
predominant symptoms, a focus of irritation is present, and progress- 
ing with its ravages; the general condition is confounded with the 
local, because correct ideas have not been entertained of the latter; 
in other words, anaemia of a majority of the organs is taken as the 
standard of the whole. 

To conclude these remarks, we may slate, that it is impossible to 
understand the derangement of the molecular action in the tissues of 
an organ ; the most that can be accomplished is to investigate the 
sensible alteration of structure which they have undergone. To know 
\hc seat of disease, is to know in which organ and tissue it is located; 
to understand its nature is to recognize in what consists the organic 
alteration which constitutes it. Pathological anatomy is employed 
in this research. The errors in pathology, says M. Boisseau, have 
arisen from the following causes: 1st, Symptoms have for too long a 
time been the sole objects of study; 2d, It has been supposed that 
th*y always faithfully represented the condition of viscera removed 
beyond the scrutiny of the senses; 3d, Physicians have neglected to 
look to the organs upon which each one of the morbific or therapeutic 
agents first exerted its influence, and the laws which preside over the 



44 [PHYSIOLOGICAL DOCTRINES.] 

propagation of this influence from one organ to another; 4th, It has 
been supposed that these agents must act upon the whole system at 
once, as they are recognized to influence a simple organ; 5th, And 
finally it has been inferred, that as the whole organism is concerned, 
all the organs were primarily affected. 

Having thus explained the laws of irritation as announced by 
Broussais, we shall now proceed to consider his theory of fever 
founded upon them. According to this hypothesis, all fevers owe 
their origin to a local irritation or inflammation, by the reaction of 
which upon the other organs, through the medium of the sympathies, 
that group of phenomena is produced winch is called febrile dis- 
turbance. Jill that class of fevers commonly termed idiopathic, 
together with certain forms of traumatic fever, are attributed to 
an inflammatory condition of the mucous membrane of the sto- 
mach and bowels, and are, therefore, denominated "Gustro-en- 
terites."* No mutter what form the fever may assume, or by what 
name it may be designated, whether ataxic, adynamic, &c, it is still 
referred to this primary lesion. Essential or idiopathic fevers are, 
therefore, regarded as chimerical, not founded in nature or sustained 
by observation. In support of this doctrine he appeals to the history, 
symptoms, and post-mortem investigation of the disease. We shall 
see hereafter how far this theory is sustained by the researches of 
those who, in the same locality, and enjoying the same advantages, 
have entered upon a similar field of observation. To establish the 
truth of the assertion, that the seat of fever is primarily local, he has 
recourse to numerous arguments, which will be detailed in suc- 
cession. 

"Inflammatory fever represents an excitement of the vascular 
sanguine system, which is the consequence of all local irritations; 
this is admitted by all nosological writers. A local excitement will 
always be found predominating; and nothing proves to us that it is 
not the immediate cause of that form of febrile movement which has 
been hitherto considered essential." "Modern writers, in considering 
inflammatory fevers as idiopathic (essential,) have not pretended that 
they were independent of local irritations, since they tell us that a 
debauch, a violent fit of anger, excessive pain of a wound, &c, 
every physical or moral cause sufficient to establish a permanent 
reaction of the vascular sanguine system, can produce fever." — "We 
are of the same opinion with them, that all the inflammations can 
produce fever, but are not prepared to admit that fever, which is 
acknowledged to arise from all local irritations, can ever exist of itself, 
which it must do if it be essential." What is meant by the terms, 
mucous fever, bilious fever, &c, if they do not depend upon corre- 
sponding irritations? According to those who use these expressions, 
the irritations which produced such fevers are not inflammations, and 
yet they are sufficiently severe to excite fever, and after death the 

*[" Gastroenteritis is observed in two forms:— with predominance of the gastric 
inflammation, and with that of enteritis. Gastric pain, loss of appetite, rejection of 
the ingesta, or difficulty of retaining them, characterize the first form: the second 
is marked by the power of satisfying thirst, and the rapid absorption of appropriate 
fluids. The other symptoms are chiefly common to both."— Ezamcn des Doctrines 
Medicates.] 



[PHYSIOLOGICAL DOCTRINES.] 45 

organs are found in a state of inflammation. Reference to the laws of 
the animal economy, the nature of life as far as its modes can be ascer- 
tained, the character of irritation, its peculiar local phenomena, and 
manner of propagation by means of the sympathies, are brought by 
Broussais to influence the weight and force of his reasoning. But he 
further endeavours to establish that the primum mobile of febrile 
disease is in the stomach and bowels. — These, of all the viscera, seem 
particularly adapted to receive morbific impressions, not only from 
the central position which they occupy, but from being in relation 
with the exterior world, and having the greatest number of sympa- 
thies radiating in all directions. By means of deleterious agents 
introduced from without, irritation is created on their mucous sur- 
faces ; inflammation succeeds, and then commences the congeries of 
diseased associations, which at all times have been regarded as fever. 
The first morbific impression, then, is made upon the stomach ; and 
it may be brought about in two ways. The first, which is direct, 
has been indicated above; the second is indirect, and arises from 
sedative impressions upon the skin, or transmitted irritation from a 
remote part. Inflammation of the stomach is always attended by a 
similar condition of the small intestines, which last are consecutively 
affected. Irritation in the organ being thus established, its character- 
istic functions will be impaired, an inordinate determination of blood 
will take place towards it: congestion of the tissues, heat, &c, are 
the consequences ; fulness of the vessels and corresponding oppression 
and weight in the abdomen follow; and the irritation, extending to 
the liver and small intestines, announce, by appropriate symptoms, 
the commencement of the malady. Hence follow loss of appetite, 
nausea, sometimes vomiting, thirst, uneasiness and pain, abdominal 
heat, with throbbing and increased sensibility to pressure. But an 
acute inflammation once begun in so important an organ, cannot 
long remain isolated ; its effects are disseminated to others. Irradia- 
tion of irritation is the ariadnean thread of the physiological doctrine ; 
it is the clue to the proper understanding of fever. The brain and 
nervous system invariably sympathize, as the next link in the chain 
of diseased associations, proclaimed by uneasiness, confusion of ideas, 
weight, and headache, disinclination to motion, intolerance of light, 
and diminution of intellectual vigour: there may be pain in the 
back, loss of muscular power, and a general state of uneasiness, 
which indicate that the spinal marrow is likewise involved. The 
cerebral disturbance becoming more intense, depression of spirits, 
augmented pain, wandering of thought, and delirium, indicate a true 
cephalitis. As every irritation of the organs is first made sensible 
in the brain and spinal marrow, as the common centre of nervous 
action, from these it is reflected anew to distant parts of the system, 
and the next in order is tin; heart. The contractions of the heart are 
augmented in force and frequency; blood is more rapidly driven into 
the arterial system of vessels; the pulse is quicker and fuller ; the 
capillaries of the skin are injected; heal and redness arc increased; 
the Becretions are impelled, and dryness results. In this way the 
feverish condition is completely established. The accession of a pa- 
roxysm of lever is usually attended with chilliness — it is because the 



46 [PHYSIOLOGICAL DOCTRINES.] 

first effect of irritation in the internal viscera withdraws blood from 
the surface and accumulates it in their vessels, causing internal con- 
gestion with its attendant sensations. The heart, oppressed, and at 
this time not sufficiently influenced by the force of sympathy to take 
on increased exertion, is feeble in its movements; but when excited 
to vigorous effort, throws off the accumulated load of blood, and 
brings about a state of reaction, assisted, in a measure, by a sympa- 
thetic irritation established in the skin. As the disease advances, the 
number of sympathetic morbid disturbances is multiplied; the tongue 
becomes dry, red at the edges, pointed, coated, and trembling; the 
lungs, liver and kidneys are more or less affected. This outline de- 
duced from the introductory account of irritation, whereby the pro- 
duction of fever is explained, evinces how impossible it would be to 
convey just ideas, were not the play of sympathies rightly under- 
stood. 

We must now enter into an explanation of the manner in which 
these laws can be applied to all the forms of fever. From the symp- 
toms which have been detailed, it will at once be perceived that they 
belong to both systems of organs — those of relation, and those for 
the maintenance of the individual. Now all the irregularities pre- 
sented by fever are referable to one of these two systems, and deter- 
mined by the preponderance of irritation in some particular organ. 
Thus, in some instances, cerebral disturbances are the most marked, 
because the intensity of irritation in the brain is greater than else- 
where : pulmonic symptoms greater than ordinary may appear and 
characterize the disease, but without altering in the least the priority 
of irritation in the stomach ; these forms are termed ataxic. Prior 
to the development of the physiological view of fever, the names 
which were employed to express the predominance of certain groups 
of symptoms conveyed no definite idea of their cause, nor did they 
inform us of the condition of the organs which gave rise to them. 
In accordance with the preceding exposition, bilious fever is nothing 
more than an extension of irritation to the liver, exciting or depress- 
ing its functions, and producing the attendant phenomena enume- 
rated in nosological treatises; and so of mucous fever, and others. 
The same disease at different periods may assume different phases 
— inflammatory in the beginning, adynamic at the termination, but 
without changing its identity. The more prominent symptoms of 
adynamic fever are stupor, a fuliginous appearance of the openings 
of the mucous membranes, small feeble pulse, cold clammy skin, and 
fetor. The rationale, according to the principles laid down under 
the head of anaemia, is evident. A concentrated vital action takes 
place in the internal organs at the expense of the external surfaces; 
the function of assimilation and chylification is wholly impaired; a 
small amount of blood is elaborated and conveyed into the general 
circulation ; imperfect hasmatosis consequently follows ; and the sus- 
pension of nervous energy and pulmonary oxygenation, add to the 
universal complication ; hence the symptoms enumerated. 

From the foregoing reasoning, and mode of explaining the pheno- 
mena of fever, the following conclusions are to be drawn: 

1st. All fevers supposed essential, are of local origin. 



[PHYSIOLOGICAL DOCTRINES.] 47 

2d. They originate in the stomach and intestines. 

3d. The affection of these viscera is inflammation ; hence it is 
called gastro-enteritis. 

4lh. This primitive inflammation is communicated to the brain, 
producing cephalitis, and finally reacts upon most of the organs, 
exciting their movements, and constituting fever. 

These are the ideas of Broussais himself upon this complicated 
and important subject, and to a great extent have been adopted by 
his pupils. Some difference of opinion, however, exists among his 
contemporaries; and the reasons for their dissent are contained in 
the various treatises which have been issued within a few years. 
Boissean, in his Pyretologie Physiologiqne, fully coincides in the 
first conclusion ; because no morbific cause acts at the same time 
upon all the organs, inasmuch as the symptoms are never referable 
to the whole of them, nor are they equally intense in those affected; 
because, in all diseases, irritation commences in some one organ, and 
extends to the others; and lastly no disease, however general, leaves, 
after death, characteristic traces of lesion in every organ of the body. 
But to the second conclusion of Broussais he enters his protest, sup- 
ported by the following facts. 1. The causes of fevers do not act 
solely upon the gastro-intestinal mucous membrane. 2. Although 
this membrane may be influenced directly or indirectly, yet this is 
not always the case, and if it is, the effect is very often of the lightest 
character. 3. Irritations of other organs can also act upon the heart, 
brain, lungs, &c, and produce fever. 4. An attentive study of the 
causes, and a close examination of the symptoms evince that the 
gastro-intestinal mucous membrane maybe untouched, or so slightly 
disordered as not to sanction the conjecture that the disease originated 
at this point. 5. After death not only no trace of lesion may be 
found in this membrane, but, on the contrary, the highest degree of 
anatomical change is observed in other parts of the body. We do 
not wish it to be understood, that gastro-enteritis is excluded entirely 
by this author, but that he merely admits the stomach to be one of 
the many organs which may be primitively affected in the produc- 
tion of fever. 

It .should be stated, that these remarks are intended to apply to all 
fevers termed essential; and that M. Boissean is as full a believer in 
the localization of disease as Broussais. When typhus fever, &c, 
ate noticed, it will be seen how far he is correct. "The two opin- 
ions, | he on<: that fever is a disease, sui generis, pervading the whole 
system, the other that it is a gastro-enteritis, are equally remote from 
the truth ; nevertheless, they both have been extensively adopted, 
inasmuch as they are well calculated to please superficial or enthusi- 
astic minds." 

Inflammatory fever is a generic term, applicable to all fevers, and 
including the whole range. When the symptoms, as the disease is 
developed, announce derangement of some organ in particular, be- 
stowing a marked character, the Bpecinc Dame is derived from this 
in: hence we have gastro-enteritis, cerebritis, &e. Another 
source of Bpecific nomenclature, is the presence of some positive or 
imaginary attendant circumstance 5 if there be prostration, for in- 



48 FEVER. 

stance, it is called an adynamic fever ; if irregular in symptoms, 
ataxic ; should there exist fetor or disordered and vitiated secretive 
action, it is variously called typhus, yellow or pestilential fever. 

A great difficulty in coming to correct conclusions with regard to 
the nature of fever, is the employment of vague and unmeaning 
terms to express the different forms under which it appears, and the 
same form is so frequently described under different appellations, that 
it is impossible to attach precise ideas to it, or to understand its signi- 
fication. It is a difficult task to locate satisfactorily in any one organ 
the invariable and exclusive causation of fever; hence the discordant 
opinions entertained as to its primary seat, or, in other words, its 
specific nature. The brain is contended, by some writers, to be the 
first affected ; the heart, the skin, the lungs, by others; while as we 
have shown, Broussais is unqualified in his gastric pathology. But 
where there is no proof of an undeviating specific location, exhibited 
by the symptoms, it is difficult to be persuaded that an acute disease 
arises from a serious disorder of any one organ, (and serious it must 
be if it can produce such intense disturbances,) while no evidence is 
present to prove that this organ is implicated. The only conclusion 
which can be obtained from these statements is, that there are as 
many primary locations of fever as there are organs, and conse- 
quently we are not to look invariably to any single one for an ex- 
planation of the phenomena. If cxclnsiveness of location is rejected, 
the first symptoms are to be expected in the organ where disordered 
action has commenced ; and whether they continue to be the most 
prominent, or in the progress of the disease are obscured by those 
which are sympathetic, their priority will lead to a knowledge of the 
first link in the chain of disease.] 

It is now time that I should state the views which I have been led 
to form on this important subject. 

First, Fevers may depend on inflammation of an acute, but more 
frequently of a sub-acute nature, of some organ or tissue of the body. 
If the inflammation be acute, the febrile symptoms will be corre- 
spondingly severe; but if sub-acute, they will assume a slighter form. 
It ought to be mentioned in this place, that the symptoms and ter- 
minations are variously modified by the organ or tissue inflamed. 

Secondly, Fevers very often depend upon mere functional derange- 
ment of some organ, having as yet no connection with inflammation; 
and here again we have a modification of the symptoms and termi- 
nations according to the organ principally diseased. 

Thirdly, Fevers sometimes depend on the mere loss of balance in 
the circulation, producing local congestions ; fevers arising from these 
last two causes are generally called idiopathic* 

After having watched the progress and termination of fevers in 

* [Although the term idiopathic fever is vague and unsatisfactory, yet in the present 
state of science it would be difficult to dispense with it. Every practitioner has met 
with some cases devoid of any predominant category of sympioms which point to a 
pariicular organ as being more materially disordered than others. In these cases it 
would puzzle the nicest scrutiny to locate the disease. The system seems literally to 
labour under a disorder which has spread itself universally through all its parts; 
hence, if the class be abolished, there would be no place for this form of diseases in 
systematic treatises.] 






FEVER. 49 

various climates, I have been led to conclude, that the nature and 
seat of fever are pretty much the same in all constitutions, in all cli- 
mates, and under all circumstances; the leading difference being in 
intensity, and the rapidity with which some run through their course; 
being sometimes connected with inflammation, sometimes not; at 
other times depending on functional disorder of some important organ 
of the body, and also upon lost balance of the circulation, by which 
means some local accumulation of blood takes place. 

Some have supposed, from the tenour of the papers which were 
formerly published by me, that I deny the influence of the nervous 
system in the production of fever; but this is far from being the case. 
It would as soon occur to me to question the laws of gravitation. I 
have always maintained the existence of a strict connection between 
the vascular and nervous systems, in producing and keeping up fe- 
brile and inflammatory diseases. 

There can scarcely be a doubt, that a disordered state of the func- 
tions of the brain, and other parts of the nervous system, occasionally 
gives rise to febrile action. It is impossible to deny to the brain, as 
an organ, that it may be disordered, like other viscera, in function, 
as well as diseased in structure. My ideas of fever may be summed 
up in the words of Dr. Fordyce, one of the best and most original 
writers upon the subject. "A fever," says he, "is a disease that 
affects the whole system; it affects the head, the trunk of the body, 
and the extremities; it affects the circulation, the absorption, and 
the nervous system ; it affects the skin, the muscular fibres, and the 
membranes; it affects the body, and affects likewise the mind. It 
is, therefore, a disease of the whole system in every kind of sense. 
// does not, however, affect the various parts of the system uni- 
formly and equally; but, on the contrary, sometimes one part is 
much affected in proportion to the affection of another part."* 

It appears to me, that certain general views closely touching this 
question are admitted by all writers whose opinions are of any value, 
although the same facts have been called by different names, and 
have led observers to draw opposite conclusions. 

1st, That the functions of almost all organs are embarrassed in 
fever from the very beginning, and often for days before the sense of 
coldness is felt by the affected person. 

2d, That«the blood leaves the surface of the body, and accumu- 
lates in internal organs, and that, unless they are overwhelmed, the 
system makes an effort to relieve herself, and certain combined phe- 
nomena take place, which are designated by the terms " reaction, 
fever." A question has arisen to determine by what means this is 
effected. There can be no doubt that it is owing to the principles of 
life. There are two circumstances, in following which investigators 
have bewildered themselves; one is, the vain attempt to ascertain 
the first link in the chain of diseased action; the other is, the still 
more hopeless endeavour to discover the principle of life, which per- 
haps no man will ever be able to unravel. 

3d, That inflammation of all parts of the body will give rise to 
fever. 

♦ Dissertation on Simple Fever, Part I, p. 27. 
o 



50 FEVER. 

4th, That inflammation may supervene during fever, without 
being the primary cause of the febrile commotion. 

5th, That the nervous system is involved as well as the vascular; 
and, 

6th, It follows as a consequence, if all these things be true, that 
the blood itself must be in a diseased condition. 

This outline of my opinions must suffice at present— it will be best 
filled up when treating of the pathology of individual fevers — when 
an attempt will be made to account for the discrepant histories which 
have been given of fevers, and for the varieties of treatment recom- 
mended by different authors. 

Division of Fevers. 

Fevers have been divided into various kinds. Dr. Mason Good 
has four orders, thirteen genera, and each genus has several species. 
This is a very erroneous plan in writing as well as teaching; for 
every individual case has some peculiarity, so that this very learned 
author might with as much propriety have made many millions of 
species. 

It was the opinion of the celebrated Dr. Rush, that it is " not more 
improper to say that men are of different species, because some are 
tall, and others short, or because some are long, and others short- 
lived, than that fevers are of different species, because they vary in 
their symptoms and duration." 

Cullen has divided fevers into intermittent, remittent, and con- 
tinued, and this last is subdivided into synocha, typhus, and syno- 
chus. 

It is my intention to reject the term "idiopathic,"* as applied to 
fevers, which I consider a most unhappy term, being one respect- 
ing which no medical man with whom I am acquainted can give a 
satisfactory definition. It seems to be a disease beyond the pale of 
pathology, having neither nature nor seat. It is defined by some to 
be a fever without a cause. Fever is alleged to be a certain combi- 
nation of symptoms, but it cannot be said that this is the disease. 
The symptoms are to be regarded as evidences of a diseased condi- 
tion of some part or parts of the system; whereas, those who speak 
of idiopathic fever, will be found very frequently to do so, either from 
habit, or from a dislike to change terms, they themselves having a 
particular meaning for it. But the schoolmen who are in the habit 
of using this term, I verily believe, do so from an erroneous impres- 
sion that the symptoms are the disease, and it is understood that 
some of them even go the absurd length of treating of idiopathic 
hectic ! 

The terms adynamic and ataxic have been also avoided in this 
work, because there seems to be no good practical reason for their 
employment. 

None of the arrangements, which have been hitherto laid before 
the profession, exactly meet my views ; and in so far as I have been 

* The fevers said lobe "idiopathic," are "intermittent, continued, and exanthe- 
matous." 






FEVER. 51 

able to observe the phenomena of fever, I believe they may be 
advantageously arranged under the following heads: 
Is/, Intermittent Fever. 

2d, Remittent or Yellow Fever : Infantile Remittent. 
3d, Continued Fever, subdivided into four orders, viz. 
Fever from functional derangement. 

from inflammation. 

from congestion. 

A mixed form of fever between these three last, but in which 
congestion predominates, commonly denominated Typhus or 
Synochus. 
4th, Hectic Fever. 

5th, Fevers attended with eruptions, subdivided as follows: 
Scarlet Fever. 
Measles. 
Small-pox. 

modified. 

Chicken-pox. 
Miliary Fever. 
Roseola. 
Urticaria. 
6th, The Plague. 

General Description of the Phenomena of Fevers. 

The following are Cullen's definitions of febrile diseases, and of 
fever : 

First, of Pyrexia. 

" After shivering, succeed a quick pulse, increased heat, with inter- 
ruption and disorder of several functions, diminution of strength, 
particularly of the joints." 

Secondly, of Fever. 

"After languor, lassitude, and other signs of debility, pyrexia, 
without any primary local affection." 

There are the strongest objections to all medical definitions. The 
following maybe urged against the two above quoted; they are 
symptomalical definitions; and it is well known by physicians of 
experience that the symptoms vary much according to constitution, 
climate, and habits of living. They vary even in different indivi- 
duals belonging to the same family, and during the same epidemic. 
The symptoms develope themselves in various degrees; one symp- 
tom, when exceedingly severe, frequently conceals or disguises the 
others. A definition to be useful either to the student or the young 
practitioner, should embrace such phenomena as are peculiar to that 
particular disease, and which never attend any other — phenomena 
which may be therefore said to be pathognomonic of the affection. 
As has been already stated, there is no case of fever, or, indeed, of 
any other disc-rise, winch has not some peculiarity that distinguishes 
it from another of the same family; in truth, the symptoms of diseases 
have B very wide range of character. A definition, giving a sketch, 
not of the symptoms, but of the nature, and scat of the disease, 



52 FEVER. 

would be a most useful introduction to the practice of physic ; but 
pathology, unfortunately, is not yet sufficiently advanced to enable 
me to adopt such a plan in this work. 

It may be asked why Cullen, in his definition of fever, has taken 
no notice of pain in the head and in the loins, delirium and coma, 
of oppression at the praecordia, of nausea, want of appetite, thirst, 
and the state of the tongue? The reason appears to me to be evi- 
dent; the mention of these phenomena would have led to the sus- 
picion of /oca I affection, which was contrary to his own dogmas. 

"Fever," says Dr. Fordyce, Part 1st, p. 7, "of all other diseases, is 
that one in which a pathognomonic symptom is least to be depended 
upon ; that is to say, an appearance which does not take place when 
there is no fever, or a fever which does not take place when there is 
no such appearance." 

Febrile diseases sometimes commence without any rigor, and 
go through their whole course without any unusual heat of skin, 
quickness of pulse, or thirst. The rigor is not always followed by 
increased heat. Languor, lassitude, and other signs of debility, are 
symptoms common to almost all diseases, and therefore should not 
be ascribed to fevers in particular. 

It is impossible to give a good general account of the phenomena 
of fevers, because, in addition to the objections urged above, they 
vary every day in the course of the disease. The symptoms which 
appear in the accession of fever, differ from those which manifest 
themselves in its progress; and these again from those which are 
observed in the decline and termination. These differences have 
given rise to a division of every fever into stages : 

1. That of accession. 

2. increase. 

3. declension. 

4. collapse. 

These stages have been differently named; the first is sometimes 
called the stage of oppression and depression ; the second, that of 
reaction ; the symptoms occurring in the third and fourth stages, 
have too frequently been called typhoid. 

The symptoms vary also according to the organs chiefly affected. 
In some cases there are decided cerebral symptoms, from the very 
beginning, indicated by headache, intolerance of light and sound, 
tinnitus aurium and delirium, or stupor with low muttering de- 
lirium, and sometimes coma, &c. In other cases the viscera of the 
thorax are principally affecied, indicated by dyspnoea, cough, expec- 
toration, and tightness in the chest, &c. In a third set of cases, some 
of the viscera of the abdomen are implicated, announced by nausea 
or vomiting, uneasiness increased on pressure, obstinate constipation 
or diarrhoea, a morbid state of the alvine evacuations, discovered 
both by their appearance and odour; a tympanitic state of the abdo- 
men, and peculiar appearances of the tongue. Occasionally, in the 
course of the fever, there are evidences of acute or sub-acute action 
in all the three great cavities, and this is what occurs in the worst 
forms of yellow and malignant fevers. 



FEVER. 53 

In fever the functions of every organ are more or less disturbed, 
so that there is the best proof of universal disorder, and the appear- 
ances so frequently seen on dissection warrant this inference. True 
it is that we now and then, on examining the body of an individual, 
find no very decided morbid appearance.* This is by no means 
peculiar to the practice of physic; for, in that of surgery, people 
sometimes die after capital operations, where there has been no loss 
of blood, and no organic lesion found upon dissection, to explain the 
cause of death. They are said to die from the shock, by which term 
I understand that the principal functions of the body become sud- 
denly impeded to such a degree that life can no longer be carried on. 
In the same way, in fevers, individuals die before any alteration of 
structure has taken place; from peculiarity of constitution, they 
cannot stand the shock produced by the embarrassment of so many 
organs in the performance of their functions ; and farther, many 
individuals cannot bear the remedies which have been thought 
necessary for the snbduction of the disease. 

Some cases of fever commence with shivering, quickly followed 
by increase of heat and other symptoms of pyrexia, and terminate 
in a few hours, after considerable suffering, by copious perspiration ; 
this is the simplest form of fever, and is termed ephemeral ; but 
when there is a regular succession of paroxysms, it is called inter- 
mittent. 

Other cases commence in the same manner, followed by heat of 
skin, &c; continue for a day or two, when the symptoms decline ; 
and there is sometimes a state of complete apyrexia, which con- 
tinues only for a short time, when they recur with perhaps increased 
violence. This kind of fever has obtained the name of remittent. 
When it occurs in infancy and childhood, it is called infantile 
remittent. When the skin becomes yellow, the term yellow fever 
has been applied. 

Another kind of fever continues for days, or weeks, without 
intermission, and is therefore called " continued fever." It has 
several varieties, of which the following are brief sketches. 

First variety. — An individual feels impaired appetite; his bow- 
els out of order; his urine scanty and high-coloured ; he passes rest- 
less nights, and at length is sensible of increased heat of skin; 
towards morning he generally Axils into a gentle perspiration, and 
enjoys a few hours sleep, from which he rises somewhat refreshed; 
he funis his tongue loaded, his breath more or less fetid ; he feels 
unwell, but slill is able to pursue his ordinary affairs. In the course 
of Hi'.- day lie is sensible of frequent slight chills, and flushes of heat; 
he becomes rather languid, has a little headache, but hopes to be 
heller alter dinner; he returns home, and although he has no appetite, 
forces himself to eat and drink, and pusses rather a worse night. 
This goes on lor several days, till at last he shivers pretty severely, 

• i eldom the case, however. The only placet! in which the physical traces 

ol disease can !"• inve tigated with doe '-.in- and deliberation, are public hospitals, 
and ibe Indifference which generally prevails is shameful. If a physician has the 
ability, he Is loo much occupied, and Borne, unfortunately for science, have neithej 
the ability nox Inclination. 

5* 



54 FEVER. 

and feels so much oppressed that he is compelled to confine himself 
to bed. Then, for the first time, medical advice is sought : the phy- 
sician can find no symptom which can be attributed to inflammation; 
there is considerable restlessness, but no great degree of suffering, 
except that which proceeds from a sense of oppression in the 
precordial region, fulness in the stomach and bowels, and pain in 
the loins; the appetite is gone, and the individual loathes food of all 
kinds, but has considerable thirst. The mental faculties are com- 
monly quite sound, but there is, perhaps, slight alienation during the 
night. 

Abstinence from solid food, and a steady perseverance in gentle 
laxative medicines, soon produce an amendment. This is the form 
which I have denominated " fever from functional derangement." 

Second variety. — A person is sometimes seized with a shivering 
more or less severe, followed by severe pain in the head, chest, or 
abdomen ; accompanied by considerable heat, thirst, full pulse, and 
every symptom which announces a sub-acute attack of inflammation 
of some structure, within one or other of the three great cavities; 
and this is the form all writers term a pure inflammatory fever. But 
when the inflammation of any part runs high, it is then said to be an 
inflammation of a particular tissue or organ. It must be recollected, 
however, that inflammation of internal organs may go on to a fatal 
termination without strongly marked symptoms. 

Third variety . — Another individual, without being sensible of 
any previous complaint, may be suddenly seized with shivering; the 
sense of coldness soon becomes intolerable ; he is unable to support 
himself in a standing or even in a sitting posture; his intellectual 
faculties are soon observed to be impaired, his features shrink, a 
deadly coldness gradually spreads over the whole surface of the body, 
his pulse sinks, he makes little complaint, and dies without the ap- 
pearance of any of the symptoms usually termed febrile. This is a 
form of disease which is certainly not very frequently met with in this 
country, but which is often seen in warm climates, and it occasionally 
attacks women in child-bed. This is the purest example which can 
be given of what has been termed congestive fever,* but it is not 
that form of it which we most frequently meet with in these latitudes, 
where it generally developes itself in the following manner:— A per- 
son, after feeling more or less unwell for some days, or perhaps for 
some weeks, experiences chilly sensations, alternating with unusual 
warmth; he is disposed to sit over the fire; feels weak, and after 
being in this situation for some time longer, with changes from heat 
to cold, the cold predominates to his sensation, while another person 
will pronounce him to be hot ; but upon careful examination, his 
extremities, more particularly the hands and feet, will be found cold; 
he makes little complaint, and is often thought to be asleep, when in 
fact he is comatose. Occasionally, however, the head is quite free, he 
suffers from slight dyspnoea, is unable to take a full inspiration, but 
has no pain. The tongue is generally moist, sometimes loaded, white 

* This is the form of fever which occurs in Rome and other places where inter- 
mittents prevail, and is termed Jievre intermittente pernicieuse, the pathological elu- 
cidation of which has been so fully pionted out by M. Bailly. 






FEVER. 55 

and shrunk. The pulse is soft, sometimes quick, at others not above 
the natural standard. Even when to all appearance he is in a com- 
plete state of coma, he can be roused, when his expression of counte- 
nance will be vacant, and appear as if he were in a state of intoxi- 
cation. If questioned as to what he complains of, he will answer, 
"of nothing," or he will move his hand towards his head, or place it 
on his breast, signifying some uneasiness, but he quickly falls into a 
comatose state again. 

Fourth variety. — The next form of fever, of which it is my duty 
to give a sketch, is that in which the patient is seized much in the 
same way as in the last described variety. He complains, however, 
from the first, of pain in his head, chest, or abdomen, has frequent 
attacks of chilliness followed by heat; with symptoms characteristic 
of diseased action in the head, thorax, or abdomen. But this state 
is quickly succeeded by more or less insensibility; slight delirium, 
rapid weak pulse; the surface of the trunk of the body feels hot, 
while the extremities are rather cold; the delirium which manifested 
itself only during the night, now becomes permanent: it is not of 
the furious kind, but that which is appropriately termed "low mut- 
tering delirium ;" the tongue, which was moist for the first few days, 
is now observed to be dry and glazed, and tremulous; he passes his 
urine and fasces in bed ; is always found upon his back, and however 
often he may be moved, will soon shrink down again towards the 
foot of the bed, which is a sign of complete prostration of strength, 
and perfect helplessness — a bad symptom in any disease. In this 
state it is impossible to rouse the patient, and it may be evident that 
he is also blind ; the pulse being quick, and so weak as scarcely to 
be felt, while the action of the heart may yet be very strong, and a 
considerable pulsation felt in the carotids or abdominal aorta. Re- 
covery is rare when the symptoms are so very severe, although the 
fatal period may be protracted to the end of the third week. Occa- 
sionally, in this form of disease, instead of the cold predominating, 
there is considerable heat, and the symptoms are pretty sharp, but 
at the termination of a few days, they become such as have been 
described above. This is the disease generally called typhus. But 
when the symptoms run very high at first, and subsequently become 
low, then it is usually called synochus. And this is precisely the 
form of disease which will be more particularly described hereafter, 
under the denomination of a mixed form of fever, from the want of 
a better appellation. The term typhus is objectionable, because it is 
sometimes used to denote a malignant or a putrid fever; at others it 
is employed to signify a nervous fever. The term synochus is also 
objectionable, for this reason, that it is stated to be of an inflam- 
matory nature, but there is a supposed union with a typhoid state of 
the system, which, although present, remains latent in the first stages, 
ami subsequently developes itself; and we are told that the appro- 
priate remedies lor inflammation are not to be employed, from a 
dread of typhus, which must inevitably follow. 

The term hectic fever, is used only to signify febrile symptoms 
consequent to some previous disease, and restricted to symptoms 
which are produced by the formation of pus in some organ or tissue; 



56 FEVER. 

in fact, whatever doubts have been entertained with respect to the 
nature of all other fevers, this is almost the only one which is uni- 
versally allowed to be sypmtomatic. 

It is considered unnecessary to offer any general explanation in 
this part of the work respecting the fifth class, viz., fevers attended 
with eruptions; or the sixth, the plague. 

Causes of Fever. 

The causes of fever are marsh miasm, contagion from human 
effluvia, and epidemic influence. These causes, together with cold, 
fear, &c, are called in medical language remote ; but I shall continue 
to employ the terms common and specific. Cnllen resolves all re- 
mote causes into sedative, in order to support his dogma of debility; 
he could not consistently allow a cause of a stimulating and exciting 
nature. Marsh miasm he supposes capable of producing intermit- 
tents and remittents only, and he restricts the term contagion to 
human effluvia, capable of producing continued fevers only. He 
considers the common causes scarcely capable of producing fevers. 
Some authors assert that there is only one species of infectious matter 
peculiar to all febrile diseases. 

No one who has attended to this subject, can deny the influence 
of contagion, and the air of marshes, on the human body ; but I con- 
ceive that too much has been hitherto attributed to them, too little to 
the previous state of the constitution, and also by far too little to the 
common causes of fever, and to internal irritations. A weighty 
argument in favour of contagion, is sometimes drawn from the well- 
known fact, of fevers spreading not only from one to another in a 
family, but also in the same neighbourhood; but the similar circum- 
stances under which the inhabitants are placed should not be for- 
gotten. The anxieties, the hopes and fears which alternately affect 
individuals attending others whom they love, the exposure to cold 
and fatigue, the night-watching and want of rest, the irregularity in 
taking nourishment, and the neglected state of the bowels, all tending 
to produce loss of balance in the circulation, and local disease, will 
go far to account for a number of individuals in the same neighbour- 
hood, and more particularly in the same family, being affected one 
after another. Neither should it be forgotten, that all these indivi- 
duals residing in the same locality, and living in a similar manner, 
may have been exposed at the same period with the person first 
affected, to the miasm or epidemic influence, or some of the common 
causes which produce fever. Why one individual should be sooner 
attacked than another, and have the disease perhaps more severely, 
it is difficult to determine. An interesting question here arises — 
What length of time does the contagion remain latent in the body, 
before it shows its effect? This is an intricate question, and one 
which has never been satisfactorily investigated. Some say it can 
be for a few days or weeks only, while others state with great con- 
fidence, that it may remain many months. Dr. Gregory used to 
assert, that contagion might lie frozen for any length of time, and 
resume its virulence upon being thawed. There are other interest- 



FEVER. 57 

ing facts, which are not sufficiently attended to in considering this 
subject. It is my belief, that contagion will not produce fever, ap- 
plied a thousand times to a person, if he be in a good state of body 
and mind. Dr. Gregory stated, that he must have been exposed to 
the influence of contagion some 20 or 30,000 times without affecting 
him once. The contagion of fever, to produce its effects, must be 
applied to a person ill-fed and clothed, or to one whose stomach and 
bowels are out of order, or who is labouring under the effects of 
some mental depression. 

From the evidence before us in the records of medicine, it appears 
that individuals residing in low marshy countries are peculiarly liable 
to fever which has been termed intermittent. The air of a marsh, 
however, does not differ in its chemical properties from that of the 
most salubrious situations; it supports combustion, and therefore 
cannot, as some have supposed, be deprived of much of its oxygen. 
If its constitution were changed, it would affect all who breathed it, 
blacks as well as whites; but this is not the fact, for there are very 
many people, who live in the centre of marshes for years, without 
being attacked by intermittent fever. I have myself had many 
attacks of this disease during a residence in a marshy district; there- 
fore, it has been in my power to investigate this subject minutely, 
not only with regard to the phenomena of the disease and its causes, 
but also the sensations produced during the paroxysms. From 
personal observation thus acquired, the first circumstances which 
attracted my attention were, that men were more liable to the dis- 
ease than females — whites than blacks — the dissolute than sober 
steady-living men ; and that agues were most prevalent at new and 
full moon. 

Women are less liable to the disease than men, because they are 
less exposed to vicissitudes of weather, their habits are not so dissi- 
pated, and they keep more regular hours. Blacks, born in the West 
Indies, are less liable to this disease than whites, partly, no doubt, 
from the nature of their constitutions, but principally because they 
have neither the means nor the liberty to indulge themselves like 
their masters. But I am convinced that difference of constitution, 
enabling blacks to resist the causes of fever better, has been very 
much overrated, and that diseases which destroy so many Europeans, 
are owing more to licentiousness than to the effects of the climate. 
The dissolute are more liable to this disease than others, because 
they often expose themselves recklessly during the night, when the 
system is in a state of collapse; and the disturbance which is created 
and kept up in the functions of important organs, by constant ex- 
cesses, must nut be lost sight of. 

Moisture alone has a great efTect in producing disease, and its in- 
fluence is speedily observed on the mind as well as the body. But 
moisture alone will not produce intermittent fever; the influence of 
excessive heat must be superadded, and then there is a rapid evapo- 
ration from the earth's surface. It is this evaporation, I imagine, 
which is productive of so much mischief to European constitutions 
in warm climates, particularly where there is any tendency to col- 
lapse. Agues are not commonly prevalent during the rainy season, 



58 . FEVER. 

when the surface of the earth is more or less covered with water; 
but they become so after the dry season sets in, when it is alleged 
"the sun acts upon the soil itself, producing deep rents, whence it is 
supposed the miasm emanates." This, however, can be more satis- 
factorily accounted for in a different manner. During the rainy 
season, white people take greater care of themselves, and are less 
exposed; the sun is obscured from the eye by dense humid clouds; 
there is, consequently, a pretty constant deposition of moisture, but 
little or no evaporation. The sun's influence becomes very great 
when the rainy season ceases, and the extent to which evaporation 
goes on exceeds all belief. It is then that severe fevers and dysen- 
teries generally prevail. 

Dr. Fergusson has observed, that " the same rains which made a 
deep marshy country perfectly healthy, by deluging a well-cleared 
one, where there was any considerable depth of soil, speedily con- 
verted it, under the drying process of a vertical stin,into a hot-bed 
of disease. 

With regard to the apparent influence of the planetary system in 
intermittents, it must be observed, that in localities where this disease 
generally prevails, the surface of the earth is scarcely above the level 
of the sea at high tides; so much so, that to prevent inundations, 
dykes are thrown up. At new and full moon the tides rise, the 
marshes become covered with water, the drains become charged, 
and the daily effects of evaporation produce the disease. I am indeed 
aware that in the interior of Ceylon, and above the Ghauts in the 
peninsula of India, where the tides cannot have the slightest influ- 
ence, agues are very prevalent, both among natives and Europeans 
at certain periods of the moon's age. I am informed by Mr. Mar- 
shall,* that in the interior of Ceylon he has seen the mercury in the 
thermometer rise from 60° to 90° in the shade : and in the sun's rays 
even to 142°. The difference of temperature to which the troops 
were exposed from 5 o'clock a. m. till mid-day, amounted sometimes 
to S2 degrees. 

Some have attempted to account for the occurrence of remittent 
fevers by the effects of excessive heat; but I believe that heat alone, 
unless the temperature be very high indeed, will not produce fever 
in any climate, till moisture be superadded, or sudden changes of 
weather take place, when the thermometer will suddenly fall twenty 
or thirty degrees, as I have myself observed in unhealthy seasons. 

It will be seen that it is not my intention to deny the existence of 
some invisible substance suspended in or mixed with the air of the 
atmosphere, and which may produce intermittent fever.t A fact may 
be mentioned, on this side of the question, which must carry con- 
siderable weight with it. It has occurred to me to see a good deal 
of intermittent fever in situations far remote from marshes, but in 
every one instance the individuals had been at some period of their 
lives in marshy districts; yet it is certainly very strange that some of 

* The well-known author of Notes on the Medical Topography of Ceylon — Hints 
to Young Medical Officers, &c. &c. 

i Some writers go the extraordinary length of speaking of the specific gravity of 
marsh miasm. 



FEVER. 59 

them never had a paroxysm during the period of their residence in 
these places, and not till months, and, in some instances, years, had 
elapsed. 

Some contagious diseases are communicated from person to person, 
by breathing the air in the apartment where the sick person is con- 
fined ; others require that actual contact should take place ; and some 
diseases are communicated in either way. In the plague, it would 
appear that actual contact with the affected individual, or with his 
apparel, is necessary; whereas, in small-pox, the contagion may be 
received merely by coming into the same room, and it is also con- 
veyed by inoculation. Contagious diseases spread slowly from one 
person to another, and from house to house, and may often be con- 
centrated within a circle, where it will attack all, or almost all, who 
are exposed to the contagion, particularly those who have not had 
the disease before. 

When we say a disease is epidemic, it is understood that we mean 
one which is produced by a certain state or condition of the atmo- 
sphere at present unknown, and which has baffled the exertions of 
every one who has entered upon its investigation. The term implies 
that a greater number of people are suddenly seized at the same 
period. An epidemic disease, after continuing for a longer or a shorter 
period, suddenly ceases, at a time perhaps when the greatest number 
of patients are affected. These are facts which appear to have con- 
founded those who assert that yellow and other fevers are invariably 
contagious. 

It does not appear that intermittent fever is ever contagious: but 
I am of opinion the yellow fever, and that which has been termed 
typhus in this country, are so under particular circumstances, and 
sometimes in a very high degree. Observation and experience have 
induced me to conclude, however, that this cause of fever has been 
very much overrated. 

In the year 1793, Dr. Chisholm made an attempt to prove that 
the fever which then prevailed in the West Indies was highly con- 
tagious, and imported from Bulam, on the coast of Africa, by a ship 
called the Han key: Similar attempts have since been made in many 
places in America, as well as in Europe, to account for the severe 
I rvers which have prevailed from lime to time. The favourers of 
importation have invariably failed in proving the disease to have 
originated in that manner, and have not been able to show that it 
had not a local origin. In the town and garrison of Gibraltar, there 
are always cases of fever, particularly in sultry weather; many are 
severe, attended by yellowness of the surface of the body, and vomit- 
ing of a dark-coloured matter, commonly called black vomit. These 
cases are considered by all candid observers to be the ordinary re- 
mittent fever, common to this and other places under similar influ- 
ences. The majority of the cases are found to occur in the lowest, 
worst ventilated, and filthiest parts of the locality. Hut in 1804- 
1810-1813-1814, and 1828, Gibraltar was visit, d 'by a fever more 
severe in its symptoms, mure fatal in us results, and attacking a larger 
proportion of the troops, as well as the inhabitants. On each of these 
occasions attempts were made to prove its importation, and that it 



60 FEVER. 

afterwards spread by contagion, and had no trace of local origin. 
Considerable doubts were, however, entertained upon this subject ; 
but in 1S14, the supporters of importation and contagion failed so 
completely in showing the foreign origin of the fever which then 
prevailed, that many sensible people were led to doubt, and others to 
deny, the truth of such views. I wish at present to confine my 
observations to the source of the fever which prevailed in the town 
and garrison of Gibraltar in 1828. 

A host of medical men, with the late lamented Dr. Hennen at their 
head, maintain that the disease was of local origin, for which there 
were abundant sources, and there is no proof of its having been im- 
ported. 

One or two others, with Sir William Pym, superintendent-general 
of quarantine, as their leader, not only insist that it was not of local 
origin, but that it was imported in a particular ship called the Dygden, 
which sailed from Havana on the 12th May, 1828, and arrived at 
Gibraltar on the 28th June. 

I have carefully perused all the evidence produced through the 
medium of the medical periodical press, and published by the follow- 
ing gentlemen :— Mr. Fraser, late surgeon to the civil hospital at 
Gibraltar; Dr. Smyth, surgeon 23d regiment; Mr. Amiel, surgeon 
12th regiment; Mr. Wilson, late of the medical staff, who I believe 
retired from the service, partly from disgust, and partly from the per- 
secution to which he was subjected, and would not submit; Dr. 
Barry, physician to the forces. Also, Sir William Pym's replies to 
queries put to him by the Royal Medico-Chirurgical Society of Cadiz 
— together with the opinions of the board of commissioners, and 
certain documentary evidence respecting the annual occurrence of 
fevers of a similar character at Gibraltar, as extracted from the 
books of the civil hospital, and authenticated by the signatures of a 
number of highly respectable gentlemen. 

After the most careful perusal of these productions, duly consider- 
ing all the facts adduced in evidence by all parties, my deliberate 
opinions are as follows: 

1st, That the fever of 182S was of local origin, and for which 
there were unfortunately abundant sources in the bad state of the 
drains, the crowded condition of the poor inhabitants, and the 
exceedingly filthy and badly ventilated state of their abodes. 

2d, That there is not a tittle of evidence to show that the disease 
was first propagated by communication with the Swedish ship Dyg- 
den. Indeed, it does not appear that there was any cause to suspect 
this ship of bringing the seeds of the disease from Havana. In the 
first place, we see from her clean bill of health, signed by the authori- 
ties there, that " this city and its neighbouring towns are free from all 
plagues or contagious epidemic disease; as likewise the said captain, 
with the fifteen men of his crew, are in a perfect state of health, 
according to the muster by his roll," &c. In the second place, we 
find the declaration of the captain, and the report of Dr. Hennen to 
the governor, the first of which bears that he "sailed from Havana 
on the 12th May, with a crew of fifteen men, all in good health. A 
few days after, two men of the Swedish part of the crew complained 



FEVER. 61 

of severe headache, and pains in the limbs, which increasing, they 
had to go to bed. Through sudorifics and purging medicine, they 
got well in eight days, so as to be able to attend to their duties. Dur- 
ing that time, five others had taken ill of the same complaint, but 
recovered in a few days, under similar treatment. A lapse of ten or 
twelve days followed, during which the whole crew were in perfect 
health ; but upon getting into a higher latitude, I met with gales and 
rain, when the greater part of the crew suffered much from wet, and. 
immediately after, those who had till then been well, were taken ill, 
probably from cold produced by the weather, yet the symptoms 
which appeared were the same as in the others. The youngest 
recovered in a short time, but the eldest two died, one after five, the 
other four days' illness, which took place on the 27th May, and. 
1st of June. The old clothes they had worn, together with ham- 
mocks, and what was in them, were thrown into the sea with their 
bodies." 

In Dr. Hennen's report to the governor of Gibraltar, dated 2d 
August, 1S2S, we find it stated, that he had minutely inspected the 
Captain and crew, « whom I found in perfect health, and I shall 
repeat my inspection before the expiration of their quarantine, on 
the 6th of the present month. In my letter of the 29th July, I 
mentioned, as the reason for putting the ship in quarantine for forty 
days, that two men died on the passage. It is now sixty-six clear 
days since the first man died, and sixty-one since the death of the 
last, and nothing like disease has since appeared, nor have I the 
most distant reason to apprehend danger to the public health, from 
any circumstance connected with the Dygden." 

3d, If the disease were contagious, it does not appear from the 
evidence to have been so in any high degree. 

•I///, It is an undoubted fact, known to every medical man who has 
been upon the rock, that remittent fever, attended by yellowness 
of skin, and black vomit, is a very frequent occurrence during the 
autumnal months. I am m possession of an authentic document, 
containing a history of the symptoms and appearances on dissection, 
■ 'I in cases of remittent lever treated in the civil hospital at 
Gibra tar, in 1881, and the five subsequent years. Having compared 
these with the cases of l s^8, I can discover nothing different. The 
two symptoms pitched upon by Sir William Pym, as pathognomonic 
Of true yellow lever, viz., yellowness of the surface and black vomit} 
Ver.e present, and the morbid appearances found alter death were 
pel fectly similar. 

The superior medical officers have bad a heavy charge made 
■gainst them in the following statement by Dr. Smyth. "At one 
period of medical rule in tins garrison* every variety of fever was 
Btdered to he returned tinder one head. Such, indeed, was the 
thraldom of the military medical press (if 1 may so use the e xp res- 
sum. .ai Gibraltar, from the termination of the epidemic U-w\- of 
i s i i. until the arrival of Dr Herman, in 1826. that it was considered 
a most wicked heresy for a surgeon of a corps to return fevers under 
any other head than simple continued fever. The consequence is, 
that although febrile diseases are the tnost frequeul ol the numerous 

6 



62 FEVER. 

cases treated both in trie military and civil hospitals, no correct table 
of fevers can be now formed from the returns of these establishments; 
no distinction whatever being drawn between the different species of 
remittent and continued. The authors of such a measure can best 
answer for themselves." Was this done to deceive the governor, or 
did it receive his approbation to mislead the authorities in England? 
This calls aloud for serious investigation, in order to prevent the 
repetition of such disgraceful management. That it could have 
been endured, can scarcely be believed, except by those who have 
been exposed to the tyrannical conduct of ignorant and obstinate 
medical superiors. 

5/h, That Sir William Pym's answers to the queries of the Span- 
ish physicians, are highly discreditable to him as a scientific man, 
and calculated to injure the public interests, however much they 
might be intended to fix him in the receipt of the salary derived 
from his sinecure office of superintendent-general of quarantine in 
Great Britain. These, answers are for the most part vague assump- 
tions — some being drawn from insufficient evidence — others from no 
evidence whatever — while many of them are at complete variance 
with the fact, of which last, the following is a notable example: — 
Answer to question 3d. " The first cases were, as I have said, in a 
house of 24 district, the situation of ivhich is healthy, very well 
ventilated, and 200 feet above the level of the sea." Now it was 
in this district of the town that the fever avowedly first appeared, 
and was for some time confined. Whether it was such a healthy, 
well-ventilated spot, or one, the air of which was saturated with 
febrific poison, the reader is left to draw his own conclusions after 
the perusal of the following statement, copied from a document 
which I received from Gibraltar. It was not written to contradict 
Sir William Pym's answer, as it never entered the writer's imagina- 
tion that the superintendent-general of quarantine, or any other gen- 
tleman who had resided at Gibraltar, could have hazarded such an 
erroneous statement. 

The district in question (No. 24.) "is situated in a natural gorge 
of the mountain, and is rendered still more close by a high wall 
raised for the military protection of the town. The wall is called 
'Charles the Fifth wall,' and is situated on the south of the town. 
The rear of the district (24), together with the whole town, is impe- 
netrably shut out from the influence of east winds by the rock itself. 
The district itself is particularly cut off from the beneficial effects of 
perflation by a high and impending semicircular bluff of the moun- 
tain, in some degree insulating it from the rest of the town, on the 
north side. Charles the Fifth wail is higher than the tops of the 
buildings in this district. This locality is therefore excluded from 
the influence of every direct wind, unless that which blows from the 
west, which was not the case when the fever broke out. Besides, 
it is deserving of particular attention, that the superficial soil was 
filthy, that the district is intersected with numerous collateral drains, 
and gives origin to several others which unite on the level below, 
and these form one main sewer which disgorges itself into the sea at 
water mark, directly in front of this part of the town. The wind 



FEVER. 63 

enters the mouth of this sewer on the beach, rushes upwards through 
the drains, and escapes through gratings (which are closely concen- 
trated in this district) loaded with offensive and noxious exhalations, 
and di Mused within a limited circle among the houses erected round, 
the mouths of the great branches. There is also a deep and common 
soil-pit in this district, which, at the commencement of the epidemic, 
was filled with impurities of every kind. In this situation a drain 
burst about the beginning of September, in the barrack-yard of the 
12th regiment, and when I saw it, its contents had broke up the solid 
pavement, and was boiling over. The atmosphere of this part of the 
town was consequently noxious, and contained within itself a suffi- 
ciency of putrid matter to have disseminated a febrific miasm over 
the whole garrison. Now, it is a remarkable fact, that the first two 
cases of the fever originated on the ground floor of a badly ventilated 
house in this district, and in the close neighbourhood of one of the 
openings of the drains; and about 50 of the cases in the beginning 
of the epidemic were distinctly traced by several medical officers to 
come from the vicinity of the openings of the drains and privies of 
this district, or in the course of the drains." 

We find the following statements made by Dr. Hennen, in his 
official communications, which I have copied from Dr. Smyth's 
paper: "That so many cases of a fever of a very serious nature have 
appeared in the barrack of the sappers and miners, on Hargrave's 
parade, which, I would observe to your excellency, is in the line 
of the drains, crossing from district No. 24, that I feel myself called 
upon to submit the propriety of immediately encamping that corps, 
and totally evacuating the barracks." In another letter to the govern- 
or, Dr. Hennen further stated : " In reference to my letter of this day's 
date, I have minutely inspected district No. 24, in company with Mr. 
Wilson of the civil hospital, Mr. Woods, the medical officer attached 
to that district, and other staff-officers; and it is with much regret 
that I have to state to your excellency, that at every step I took in 
that district, I had reason for surprise, not that fever had broken out 
there, but that it had not extended farther. From whatever causes 
it may have proceeded, the pauper population is dense to a degree 
incredible, except to those who have seen it. In sheds without ven- 
tilation, without drainage, and generally composed of the slightest 
materials; in tiers of beds as close as in a crowded transport, nume- 
rous individuals sleep. They go out to their work at an early hour, 
and return at gun-fire, locking up their miserable places of nocturnal 
■belter during the day, and leaving them saturated with the steam 
of their bedding, their food, and the overflowing receptacles of their 
ordure. The detail would be too disgusting to enter into; but I most 
respectfully submit to your excellency, the indispensable necessity 
of sweeping away the whole of these sheds, which I have every rea- 
son to Buppose are unauthorized by the government." A commission 
Was subsequently appointed by the governor's orders, to inspect the 
different districts of the town, which way composed of military as 
Well as medical officers, and I copy the following statement from 
their report: "In the course of our inspection, we were struck, at 
. Step we took, with the density of the population." So mueh 



64 FEVER. 

for Sir William Pym's answer to the 3d question, in which he has 
given a confident assurance of the healthy situation and well-venti- 
lated state of No. 24 district, where the first cases of fever occurred 
in 1828. Both statements cannot be true, and I am sorry to say 
there are many other points in the same predicament. I wish it were 
possible for me to reconcile them with each other, not only on account 
of the reputation of Sir William Pym, as an old officer, but for the 
credit of the department to which he belongs, and the judgment of 
the authorities who appointed him to the lucrative situation of su- 
perintendent-general of quarantine in Great Britain. 

6th, It is my opinion that the board of commission was not hap- 
pily chosen by Sir George Murray. No medical officer should have 
been nominated, or any other individual, however exalted his rank, 
who had previously expressed decided opinions on the subject to be 
investigated. 

7th, I humbly conceive Sir George Don, the governor, acted con- 
trary to his orders, and certainly he did not act wisely, by delegating 
his authority as president of the commission, to any individual, and 
more particularly to Sir William Pym, the superintendent-general 
of quarantine, who immediately nominated his newly-acquired par- 
tisan, Dr. Barry, to be secretary to the commission. That Dr. Barry 
is an ingenious gentleman is well known ; that he changed his opin- 
ions very suddenly at the time of Dr. Hennen's death is alleged, and 
has not been satisfactorily disproved; and that he immediately 
adopted the opinions of his new chief is undoubted. Whether Dr. 
Barry, in his capacity of secretary, gave colouring to the evidence 
produced before the commission, or improperly put leading questions 
to the parties examined, to favour the views of his chief, is best 
known to those who were present at the investigations. But it will 
be admitted, that such functionaries as president and secretary should 
not have been chosen from a class of persons to whom the slightest 
suspicion could be attached. On the list of the commission, I find 
another name as exceptionable as those of Sir William Pym, and Dr. 
Barry, viz., that of Dr. Broadfoot, superintendent of quarantined 
Gibraltar. Besides these, there are also the names of two official 
gentlemen, the captain of the port, and the town major, who were 
thus also improperly placed in a situation either to accumulate or re- 
ject evidence, which might show inattention or dereliction of duty to 
such an extent as to compromise their situations ! The only unexcep- 
tional appointments on the commission were those of Colonel Chap- 
man, civil secretary, and Judge-advocate Howel,andthe coincidence 
of their opinions is quite remarkable. 

Colonel Chapman's opinion is as follows : — "Judging from the evi- 
dence produced before the board, the manner in which it has been 
given, together with the description of persons who have been brought 
forward as witnesses, I am decidedly of opinion, that the late epidemic 
disease is of local origin. As to the importation of the late epidemic, 
I am of opinion, that the attempt to prove the introduction of the 
disease, after many months of fruitless inquiry by those ivho wish 
to prove it, has totally failed." 

Judge-advocate Howel gave the following opinion :—" Upon a 



FEVER. 65 

careful review of all the proceedings before the board, I am of opin- 
ion, that the evidence brought forward has totally failed to prove that 
the late epidemic disease was introduced from any foreign source, 
either by the ship Dygden, or by any other means ; and I am further 
of opinion, that the late epidemic had its origin in Gibraltar-" 

From Botta's History of Tuscany, the following statements are 
extracted respecting the epidemic yellow fever which prevailed in 
Leghorn, in 1S04. " It was occasioned, as it appears, by the pre- 
valence, during the summer of that year, of south winds, unusually 
warm and rainy; this sickness was by some termed the yellow fever, 
by others the black vomit ; both names which agree well with the 
symptoms which mark it. It began to rage in the lowest quarters 
of the city, and those most crowded and filthy ,io such a degree that 
some were cut off in seven days, some in five, others in three, and 
even in the short space of one day." u The disease was most violent 
in robust young men, more mild with the weak, the old, and with 
females; but almost all those last, attacked when pregnant, died; 
almost all the children escaped." Speaking of the remedies, it is 
remarked, " On the other hand, it was found, that from the air being 
impregnated with animal exhalations, the disease was more easily 
propagated, and the person infected was more violently attacked ; 
and a confirmation of the argument was found in the circumstance, 
that the quarters of the city most filled with filth, and the houses of 
the poor, were the chief seats of the disease. On the contrary, the 
airy quarters, and where the houses were neat and clean, and enjoyed 
open and free air, were either exempted, or did not become worse, 
or the infection did not spread from one body to another." " It did 
not extend into the country, although persons in numbers, and goods 
in quantities, were transported and spread from district to district, 
ami from the city to the country." On this occasion, also, an attempt 
was made to prove the importation of the fever from Vera Cruz, but 
was not successful. 

When the yellow fever prevailed in Philadelphia, in 1794, the 
celebrated Dr. Rush was most shamefully persecuted by the authori- 
ties, t" whom many of his medical brethren unhandsomely lent 
themselves, for having proved thai the yellow fever existed in that 
city— that it was generated in the place, and had not a foreign origin. 
It is now more than forty years ago; and after reading the report 
made on the subject by his opponents, I can readily join Dr. Rush in 
his conclusion, that "it is impossible to review this report, without 
blushing lor ihe shameful submission made, by the science of medi- 
an' •, to the commercial spirit of the city." 

It iiny he useful to my readers to know the evidence which Dr. 
Rush produced to show the local origin of the fever, and it will be 
observed that an attempt was made on this occasion to fix its im- 
portation on a ship. " It was produced," says Dr. Rush, « by the 
exhalations from the gutters and the stagnant ponds of water in the 
neighbourhood "f the city. Where there was most exhalation, there 
w<n; most persons affected by the fever. Hence the poor people, who 
rally live in the neighbourhood of the ponds in the suburbs, were 
the greatest sufferers by it. Four persons had the fever in Spruce 

6* 



66 FEVER. 

street, between Fourth and Fifth streets, in which part of the city the 
smell from the gutters was extremely offensive every evening. In 
Water street, between Market and Walnut streets, many persons 
had the fever: now the filth of that confined part of the city is well 
known to every citizen. On the 25th August, the brig Commerce 
arrived in the river from St. Mark. After lying five days at the Fort, 
she came up to the city. A boy who had been shut out from his 
lodgings, went in a state of intoxication and slept on her deck, exposed 
to the night air, in consequence of which the fever was excited in him. 
This event gave occasion for a few days to a report that the disease 
was imported; and several physicians, who had neglected to attend 
to all the circumstances that had been stated, admitted the yellow 
fever to be in the town. An investigation of this supposed origin of 
the disease soon discovered that it had no foundation." 

Vitiated air,* and the effluvia which proceeds from the bodies of 
individuals crowded together in jails, hospitals and ships,have always 
been abundant sources of fever. Dr. Fordyce mentions instances 
where sheep and hogs were transported, during the American war, 
from England to America, in the holds of ships, in which many were 
confined in a small space: an infectious fever frequently broke out 
among them, which destroyed great numbers. 

History affords many melancholy examples of the baneful effects 
of vitiated air and human effluvia, and the speed with which they 
destroy animal life. The best example is to be found in the occur- 
rence which took place last century in the Black Hole at Calcutta. 
One hundred and forty-six unhappy individuals were forced into a 
dungeon, about eighteen feet square, at eight o'clock at night, and at 
six next morning, when released, only twenty-three came out alive; 
most of these ivere in a high putrid fever, and subsequently died. 

It becomes an interesting question, but one too extensive for this 
work, how contagion propagates itself, and to which part of the 
body it is first applied? In this inquiry, we shall be much assisted 
by the circumstances which are observed to take place after inocula- 
tion with small-pox. The mucous membrane of the lungs seems to 
be one of the first parts in which the diseased action is to be detected ; 
and careful observation has induced me almost to believe, that in 
diseases produced by contagion, the bronchial membrane rarely, if 
ever, escapes. 

Fourcrois tells us, that in several of the burial-grounds in France, 
in which the graves were dug up sooner than they ought to have 
been, the persons employed have occasionally been asphyxiated ; 
those who were standing at a little distance, were often affected with 
vertigo, fainting, nausea, loss of appetite, &c. History affords us 
remarkable instances of the occurrence of diseases decidedly epi- 
demic : the most ancient are those which will be found in sacred 
writ, in which we find, that on one occasion seventy thousand per- 
sons were destroyed by pestilence in three days' time ; and we are 
told, also, that one hundred and eighty-five thousand persons were 
destroyed in the Assyrian camp in a single night. The most re- 

* It is to be regretted, that the term malaria is not restricted to foul air, according to 
its literal meaning. 



FEVER. 67 

markable epidemic of modern times, is the cholera of the East, which 
extended itself in the very teeth of tempestuous winds. 

Pythagoras first started an opinion respecting critical days, and 
he had an unlimited belief in the occult powers of certain numbers. 
Hippocrates seems to have entertained similar opinions; and it is an 
essential part of the old doctrines of concoction, according to which 
it was supposed that a separation of the morbific matter had a ten- 
dency to take place on one of the critical days, by a discharge from 
the skin, bowels, kidneys, or blood-vessels. 

I have no belief in the influence of critical days, although I admit 
that the crisis frequently takes place in some of the ways mentioned. 
When an organ is affected with disease, there is a constant effort of 
nature to throw it off: this effort is, in truth, one of the great prin- 
ciples of life, and its object is effected by a determination of blood 
to another organ : occasionally, a spontaneous discharge of blood 
takes place. 

From the time of Hippocrates, it has been generally believed that 
fevers have a tendency to remit on the 3d, 5th, 7th, 9th, 11th, 14th, 
1 7th, 20th days, and even the 21st.* Many modern physicians have 
adopted this doctrine; but I doubt much whether it has not proved 
more injurious than beneficial in the treatment of disease. Often 
may physicians be seen prescribing a placebo, because the critical 
day is at hand, when they ought to be actively employed in eradi- 
cating the disease. When attending to this point, I have very often 
found the calculations made erroneously ; and not unfrequently I 
have seen physicians disagree as to which was the proper critical 
day — one calculating from the period when the rigor took place — 
another from the period when the heat of skin occurred — and I have 
seen a third calculation made from the time when the patient con- 
fined himself to bed. There can be little doubt, that fevers and 
other diseases have a tendency to run through a regular course, and 
when they terminate favourably, this happy event generally takes 
place upon the occurrence of an eruption, or of some discharge, as 
by diarrhrca, copious perspiration, flow of urine, expectoration, &c. 
It cannot be denied, however, that in some diseases there is a strong 
tendency to periodicity, but far more so in the accession than termi- 
nation. Thus, in intermittent fever, the attack may come on regu- 
larly at the usual period, but each stage may occupy a shorter or a 
longer space of time in one paroxysm than another. Sometimes an 
individual dies in the cold fit, but much oftener the hot fit is not re- 
lieved by sweating, and his disease becomes a continued or remittent 
fever, or inflammation of a particular organ takes place. But it is 
of little importance whether the doctrine of critical days be true or 
false, if tin; physician acts wisely, and neglects nothing which can 
tend to reduce the diseased action. 

[♦ This question will be recurred to in the following pages.] 



INTERMITTENT FEVER. 



INTERMITTENT FEVER. 



Of all the febrile diseases, intermittent is generally the simplest in 
form. It is composed of three stages, beginning with a cold fit, fol- 
lowed by heat, and terminating in profuse perspiration. It has been 
known from the earliest ages, and is most prevalent in some parts of 
North and South America ; the Pontine marshes near Rome ; in 
Holland ; and in the fens of Lincolnshire and Cambridgeshire in 
England. We are told that, in the sixteenth century, this fever was 
very prevalent, and proved fatal to a great number of people in 
London; and in the year 155S it raged like the plague, and was also 
very fatal ; but it has become less frequent in Great Britain, which is 
to be ascribed to the increased comforts of the people, to their habits 
of cleanliness, and to the improvement, which has taken place in the 
climate, owing to the draining of lands, and cultivation of the soil. 
It has been stated, but, I believe, without foundation, that a miasm 
producing intermittent fever, is generated in London, in the neigh- 
bourhood of St. James's Park. Intermittent fever is of very fre- 
quent occurrence in all warm countries, and is one of the purest 
specimens of a disease depending upon an irregular determination of 
blood, in which the system is often relieved by the unaided powers 
of the constitution. 

Cullen's definition is, " Fevers arising from marsh miasmata, con- 
sisting of many paroxysms, with intermission, or at least with evident 
remission intervening, returning with remarkable exacerbation, and 
in general with shivering ; one paroxysm only in a day." 

Like most symptomatical definitions, this is very exceptionable. 
Paroxysms of intermittent have taken place from sudden change of 
atmosphere in situations where no miasm ever existed ; and the most 
severe cold stage which ever came under my notice, and which 
lasted twenty-six hours, was produced by exposure to frost after the 
individual had got wet on the top of a coach. Mr. John Hunter 
informs us, that two children had ague from worms; they took bark, 
but it did them no good; but the worms were destroyed, and they 
got well. We have, in like manner, says he, agues from many dis- 
eases of particular parts, more especially of the liver and spleen, and 
from an induration of the mesenteric glands. Many instances are 
also recorded from repelled eruptions, the drying up of old discharges, 
as well as from the application of cold. 

Sir George Baker has given an account, in the Medical Trans- 
actions, of an intermittent that prevailed in 1780; it affected the 
inhabitants who lived in the higher parts of the country, while those 
in the marshes escaped. Sir Gilbert Blane informs us that while the 
village of Greenhythe, nearly on a level with the marsh at North- 
fleet, is unaffected with intermittent fever, the adjacent hills suffer 
considerably from it. 

There are usually reckoned three kinds of intermittents, the tertian, 
the quotidian, and the quartan. But they ought strictly to be re- 
garded as the same disease, with a longer or a shorter interval ; and 
the one frequently runs into the other. We often, however, see a 



INTERMITTENT FEVER. 69 

double quotidian. I have observed, that the longer the interval, the 
more severe is the paroxysm, and vice versd; but there are many ex- 
ceptions. Tertian is employed to express that form of disease in 
which there is an interval of forty-eight hours from the commence- 
ment of one attack to that of another ; Quotidian, twenty-four; 
and the Quartan, seventy-two. 

[Other forms — reduplications of these — are occasionally observed 
in the United States. As, for instance, double and triple tertians. 
The former may be mistaken for quotidians, a paroxysm occurring 
every day, but varying in'intensity, time of access, duration, &c. ; 
every other paroxysm will, however, be similar. The latter exists 
when two paroxysms occur every other day, and a single one on 
the intermediate day. Innumerable types are described in the 
systematic treatises upon intermittent fever. We once witnessed 
the return of a single paroxysm every two weeks, for three months 
in succession; and with the utmost difficulty its recurrence was at 
last prevented.] 

Phenomena of Intermit tents. 

When an individual has once had an attack of intermittent fever, 
he is afterwards more liable to the disease, and is sensible of its ap- 
proach some time before any one suspects him to be ill; the toes and. 
the last joints of the fingers feel cold and benumbed, and the nails 
have a bluish colour; he has sensations of languor, and long fits of 
yawning; occasionally at this period there is headache, sometimes 
stupor, and pains in the back and loins. 

Cold stage. — When the paroxysm actually commences, the patient 
feels the extremities cold, with a sensation as if a small stream of 
very cold water were flowing down the spine, which extends itself to 
the thorax and abdomen. He has great desire for warm drink, and. 
to cover himself with as many bed-clothes as can be procured ; the 
prostration of muscular power is considerable; the sense of cold very 
HMD becomes insupportable; the teeth chatter, and there is a univer- 
sal tremor over tin- l>ody; and if I can trust my own sensations, and 
the accounts of others, the tremors affect internal as well as external 
parts. These tremors sometimes terminate in convulsions. The 
respiration is always laborious, short, and hurried, and the individual 
ia unable to take in a deep inspiration when desired; a short hard 
cough frequently attends, without expectoration; there is great 
oppression at the priecordia. Some individuals complain most of 
headadu', some of pain in the back, in the lumbar region and lower 
extremities, and others of universal pain. In almost all cases the 
patient is incapable of attending to any thing. Sometimes there is 
Stupor, and at others, coma or delirium. The features are much 
shrunk and pale; the eye looks dull and hollow, while the cheeks 
and hps are more or less of a livid hue. The pulse is oppressed and 

weak, sometimes slow, a! others quick, and frequently intermits ; but 

il"' violence of the tremors renders it often impossible to feel the 

pulse distinctly. The tongue is moist. It is a curious circumstance, 
that while the patient complains of intense cold, the heat of the body 



70 INTERMITTENT FEVER. 

every where, except in the extremities, is sometimes above the natu- 
ral standard. 

The paroxysm occasionally comes on without any rigor, instead of 
which the patient feels a slight sensation of cold, or severe headache, 
is lethargic, or affected with languor and yawning. Sometimes the 
paroxysm is announced by violent articular, lumbar, and frontal 
pains; and sometimesa patient falls into a profound sleep forseveral 
hours, and awakes in a violent hot stage. These various forms are 
called by the vulgar the dumb-ague. It sometimes happens, that at 
the next attack, instead of a regular paroxysm, a violent pain is felt 
in the situation of the snpra-orbitary foramen, and extends to the 
brow, affecting the nervous twigs of the frontal branch of the fifth 
pair; this pain often continues for many hours, and seems to resemble 
the tic douloureux. But it would be vain lo attempt a description 
of all the appearances which this disease occasionally assumes. 

The duration of the cold stage is very various, rarely less than half 
an hour, and seldom exceeding four. It sometimes happens that an^ 
icy coldness steals over the whole surface, and in aguish countries it 
is not an uncommon circumstance for persons to die in the cold stage. 

Hot stage. — After the cold stage has continued for a longer or 
shorter period, the hot stage commences; the one gradually runs 
into the other, there being no distinct interval between them. The 
change is attributed by patients themselves to the treatment which 
has been employed, or to the effects of vomiting, which sometimes 
accompanies the cold stage. The skin becomes hot and dry, some- 
times pungent; the face flushed and swollen; the thirst urgent, the 
tongue parched; there are restlessness, general uneasiness, and op- 
pression at the praecordia ; the respiration is hurried and anxious; 
and almost invariably, the patient complains of acute pain in some 
region of the body, generally in the head and lumbar region, very 
often also in the thorax, and left hypochondrium ; there is frequently 
a slight degree of disturbance in the mental faculties, sometimes, in- 
deed, delirium. On some occasions there are symptoms which an- 
nounce cerebral disturbance, viz., severe headache, tinnitus aurium, 
and throbbing of the carotids, &c. The pulse is frequently quick, 
sharp, and bounding, even in patients whose health and strength are 
already much impaired. 

I have seen the thermometer, the accuracy of which had been well 
ascertained, rise in the hot fit, even in this country, to 110°, and in 
warm climates it is stated to rise as high as 112°. 

The duration of this stage varies more than the former; in general, 
it continues from four to twelve hours, and terminates in perspiration: 
but on some occasions the febrile symptoms continue for several days 
or weeks, when the disease is termed a continued fever; now and 
then there are marked remissions followed by exacerbations, when it 
is called a remittent: in addition to the last-mentioned circumstances, 
there are sometimes considerable irritability of stomach, black vomit- 
ing, and a yellow tinge of the skin ; then the case is termed a bilious 
remittent, or yellow fever. 

Sweating stage. — After the hot stage has existed for some time, it 
terminates in the sweating stage ; the perspiration appearing first on 



INTERMITTENT FEVER. n 

the forehead, arms, and legs, soon becoming general and profuse. It is 
difficult to calculate the quantity of this excretion in any case ; but it 
is admitted by all who have attended to the phenomena of intermit- 
tents, to be very great. From the moment the perspiration begins to 
appear, the uneasy sensations, and other symptoms above described, 
begin to subside, and generally vanish after it becomes copio.us.* 

Many patients fall into a profound sleep for several hours, and then 
awake quite refreshed; others complain much of weakness, while 
some whose constitutions have not been previously injured, are able 
to resume their ordinary duties almost immediately. 

When this disease continues for some time, the patient not only 
becomes weak, and loses flesh, but he has no interval of ease ; each 
paroxysm increases his sufferings, and he feels comparatively little 
relief from the perspirations, which he often prolongs, in the vain 
hope of alleviating his symptoms. He complains of headache, intole- 
rance of light and sound ; or he has a cough and dyspnoea, which 
will almost always be found to depend on inflammation of the lining 
membrane of the air passages: or he has constant thirst, flatulent dis- 
tension of abdomen, constipation, or diarrhoea, with griping pains in 
the bowels, a dull pain and sense of weight in both hypochondriac 
regions, more particularly in the right. The skin continues hot, and 
feels harsh; the feet and legs frequently become ©edematous; the ab- 
domen permanently tumid ; the urine scanty; the tongue dry at the 
tip, the rest of it being furred ; the patient passes restless nights; and 
perhaps in the very next paroxysm he may die in the cold stage; or 
the sweating stage may not succeed the hot, and he may die in a few 
days of continued or remittent fever; or decided marks of inflam- 
mation of the brain, liver, lungs, &c, take place and he is cut off 
from the effects of disorganization in these organs. Such circum- 
stances are of frequent occurrence in warm countries, where inter- 
niittents prevail ; many such melancholy examples will be found, by 
referring to the works of Sir John Pringle and others; but more 
particularly to Sir James Fellowes's reports of the destruction occa- 
sioned by this fever among our troops employed in the expedition to 
Walcheren. The history of the fever which annually prevails at 
Koine, and which has been so ably and faithfully described by M. 
Bailly, also corroborates the above statements. 

TIii.n fever sum. 'times attacks individuals when labouring under 
internal diseases, such as dysentery, hepatitis, &c, and I have fre- 
quently Mill a remittent converted into an intermittent. It may also 
Dfl mentioned, that enlargements of the parotid take place during the 
course of inlermittents. The gland increases in size and hardness 
during each cold fit, and it seems, in the first instance at least, to owe 
its enlargement to Banguineoua engorgement; subsequently, the gland 
suppurates. 

It has already been mentioned, that when intetmittents have con- 

• M. Andr.'ii, in the first pari of lii^ vi'ry excellent pathological writing*, p. 477, 
mention* a very carious case. A jronng man, who bad been nemlplegic on tne left 
side of in. body from hi* Infancy, wa auacked witb tertain Intermittent, He only 
perspired on thai half of hi* body which bad not been paralysed. He slated thai in 
iitii he never perspired bin on one arm and leg, and one side of bis face 
and h 



72 INTERMITTENT FEVER. 

tinued for some time, the lower extremities frequently become cede- 
matous, the belly tumid, and sometimes even ascites takes place. The 
first does not denote danger, but the last always occasions an appre- 
hension of an organic lesion of some important viscus. Nevertheless, 
both may be occasioned by mere functional derangement. In these 
cases, the thirst is considerable, the secretion of urine scanty, and 
sometimes dysenteric symptoms manifest themselves. 

Appearances found on Dissection. 

The following appearances have been observed in the bodies of 
those who died in the cold stage. — The vessels of the brain gorged 
with venous blood ; and the carotids, after passing into the skull, 
may sometimes be seen greatly distended with black blood. The 
lungs much congested, of a dark colour, which is the condition de- 
scribed by the older writers, by the term " putrid state." In the very 
few instances which have fallen under my own observation, I have 
not observed any structural disease in these organs : for, upon making 
sections, and squeezing them in water, they have resumed their na- 
tural appearance and buoyancy. The heart, and veins near it, are 
gorged with blood ; and sometimes an effusion of blood, or blood 
serum, is found in the cavity of the pleura. In the abdomen, dark- 
coloured patches are sometimes seen on the peritoneum, occupying a 
considerable extent of the intestinal tube ; and, upon cutting through 
these portions, all the tissues are found highly injected, and it is pro- 
bable that this appearance has often been mistaken for mortification. 
The liver is sometimes gorged with blood and discoloured ; but when 
treated, like the lungs, in water, this organ is restored to its natural 
colour, unless it has been altered in structure by previous diseased 
action ; when it is easily broken down, like coagulated blood. I have 
seen the spleen in a similar state; but was not able, by washing, to 
restore it to its natural appearance. The stomach and intestines 
contained, in one instance, a dark, sanguineous-looking matter, like 
the black vomit. 

In corroboration of the above statement, as well as in proof of the 
pathological and practical views yet to be detailed, I beg to subjoin 
a short account of some of the interesting cases and dissections de- 
scribed in the excellent work of M. Bailly,* whose zeal in the cause 
of science led him to visit Rome in the sickly season, for the purpose 
of investigating the nature and seat of intermittent fever. 

"Case I. — Benoit Simouelli, set. 30 years, of a strong constitution, 
affected for some time with a tertian fever, came to the hospital on 
the 2d July, 1822. 

" 3d, Had a slight febrile access, afterwards took §ij, of bark. 

"4th, Towards mid-day, he walked in the yard, felt very well, 
and laughed with the other patients. All of a sudden, he was seized 
with violent shivering, to which succeeded a very high fever, during 
which he had alternate flexion and extension of the forearms, and 

♦ Entitled Traite Anatomico-Pathologique des Fievres Iniermittentes, Simples et 
Pernicieuses. 1825. 



INTERMITTENT FEVER. 73 

profound coma. He died in six hours after the commencement of 
the attack. 

" Dissection the following day at 2 o'clock, p. m. — Vivid injection 
of the whole of the arachnoid: colour of the cineritious matter of the 
brain much deeper than natural, approaching a dark reddish gray; 
a little water in the ventricles. No false membrane on the arach- 
noid. Great inflammation of the stomach, especially towards its 
great curvature, which was everywhere of a deep, generally diffused 
red. Many worms in the small intestines, which presented also in- 
flamed portions, especially where the ascarides had collected. 

"Case III.— Pierre Donati, aet. 28, of a good constitution, was 
brought to the hospital of Saint Esprit on the 2d August, 1S22. 

<■ An hour and a half after mid-day, he was seized with an acces- 
sion of fever, which commenced by excessive coldness followed by 
intense heat, and stupor. He lay upon his back, with his eyes half 
open. He awoke when any one spoke to him, and fell again into 
the same state of coma. His pulse was frequent and strong; the 
skin burning. In the night copious sweating appeared, the intel- 
lectual faculties returned, and in the morning he was in a state to 
answer concerning his health. Took several ounces of bark. 

" 3d, The fever returned half an hour after mid-day. Commenced 
with a very violent coldness, followed by heat and stupor, but never- 
theless, he always awoke when any one called him, and he opened 
his eyes. The forearms were bent upon the arms, and could not 
be extended; the teeth were clenched, which prevented the state of 
the tongue from being seen. Sensibility of the skin diminished. He 
lies upon his back. There is no pain upon pressing the belly. At 
half past two o'clock, general perspiration, but not so abundant as 
the first. In the evening, return of sensibility and intelligence. 
Cessation of contraction of the arms. But the ideas are less clear. 
Other doses of bark. 

"4/A, Tin; morning of the third day after his arrival, at half past 
7 o'clock, the pulse was frequent ; stupidity; together with a drunken 
appearance. At 11 o'clock, a return of the cold, subsequent fever 
more violent ; stupor more profound, coma, return of the rigidity of 
the limbs; subsultUS tendiiiiun ; he always lies upon his back; pulse 
full and strong. Ai hill past 3 o'clock, sweat appeared, but less 
copious. After the sweat, he could not give an answer, and he was 
Unconscious of his own stale ; cessation of the contractions. Died at 
10 o'clock in ihr evening of the 5th. 

" Dissection twelve hours after death. — Lively inflammation of the 
whole of the arachnoid ; serosity between the circumvolutions, with 
engorgement of the vessels; injection of vessels of the lyra. The 
brain being mi- 'l. there escaped half a pound of blood. Some 

points of a red colour in the stomach and intestines; liver gorged with 
.; spleen voluminous and easily torn. No morbid appearance 
in the chest. 

' " IV. — Francois Lauiein, shoemaker, aet. (50, of a lean con- 
stitution, kill sick on the 17th August, 1S22. lie had the lever 



74 INTERMITTENT FEVER. 

every day, beginning with shivering, and terminating in the night 
by sweating. At the same time he was constipated, and had pain 
in the epigastrium. Was brought to the hospital of Saint Esprit on 
the 24th August. In the evening, the surface of his whole body 
was of a deep yellow citron colour; said this colour appeared during 
the last paroxysm ; extremities cold, while he had a feeling of internal 
heat; tongue red and dry; pulse 108, like a thread. He had still so 
much recollection, that he smiled on seeing us approach him, for we 
had already spoken to him when he was brought to the hospital, 
and before he was yet put to bed. He complained of nothing, ap- 
peared quite tranquil, and replied perfectly to all that we asked him. 

"25th. — In the morning he was found in a state of coma; and 
died at 10 o'clock, a. m. 

" Dissection. — The body was of a lemon-yellow colour. On open- 
ing the head, the dura mater was tinged as yellow as the skin; by 
repeated washing this tint could in part be removed ; but on holding 
it to the light, the diminution of colour was scarcely perceptible; in- 
jection of the arachnoid; cortical substance of a deep colour: yellowish 
serosity between the convolutions. On slicing the brain, a number 
of red points were seen; a little water in the ventricles; the cere- 
bellum natural; the lungs healthy ; the cavities of the heart appeared 
to us larger than usual ; in the right ventricle, was a clot entirely 
formed of albumen, as yellow in colour as that of the skin and dura 
mater. The belly, before being opened, was concave, and resting 
on the vertebral column; the stomach contracted on itself; it was 
everywhere of the colour of lees of wine. Although it was well 
washed, there adhered to its surface a thick mucus, similar to 
the tenacious expectoration of patients labouring under pulmonary 
catarrh. The smaller curvature, and a portion of the greater, pre- 
sented that kind of eruption described at No. 30. When examined 
with a lens, it offered nothing more remarkable than to the naked 
eye, only instead of appearing to consist of small perfectly round 
elevations, and entirely separated from each other, they communi- 
cated by their bases. The redness of the stomach was less lively 
towards the pylorus, but it began immediately at the duodenum, 
where it was very intense, and continued without interruption in the 
small and large intestines. The gall-bladder was green externally, 
and filled with a black and thick bile ; on pressing it strongly, only 
a few drops could be made to pass into the duodenum; the orifice of 
the ductus choledochus could not be distinguished, in the midst of 
red, bloody, and swollen folds of the mucous membrane of the duo- 
denum, but by this means. The ductus choledochus being opened, 
presented nothing remarkable, except that its mouth was drawn into 
the duodenum, in consequence of the swelling of the inflamed 
tissue of the latter. The liver was of ordinary consistence ; its colour 
was of the yellow of powdered bark: this is the only time I ever 
saw it in this state. The spleen was of the usual size, and quite 
diffluent. 

" Case V.— Jean Olivier, ret. 40, of a good constitution, was brought 
to the hospital on the 6th July. He was then without fever. In the 



INTERMITTENT FEVER. 75 

evening the fever came on, preceded by shiverings, and followed by- 
violent heat. Pulse strong, 120; coma. He lies upon the back. 
Right arm immovable. The left arm bent and carried towards the 
head. Sensibility everywhere. When an attempt is made to open 
the left eye, he appears to experience pain, and contracts the eyelids. 
Belly painful. 

"1th, In the morning. — Coma; lies upon the back; pulse strong, 
10S. He died at seven o'clock, p. m. 

" Dissection. — Injection and thickening of the arachnoid; engorge- 
ment of the vessels which run on the convolutions, which are sepa- 
rated by watery exudations; the left Jyra greatly injected; watery 
effusions at the base of the brain ; phlegmonous eminences in the 
stomach; which were of a gray slate colour; invagination of the 
small intestines; spleen voluminous and pulpy. 

"Case VI. — Vincent Orsini, set. 60, came to the hospital the 3d 
July lS22,in the following state : Coma; pulse insensible; extremities 
cold ; demiflexion of the two thoracic extremities; when an attempt 
is made to extend them, a resistance is felt on the part of the flexor 
muscles. Left eye half shut, right eye open, pupils dilated, im- 
movable ; tongue dry, lying in the very bottom of the mouth. He 
manifests pain when pressure is applied to the belly. Died the same 
evening. 

"Dissection. — Vivid inflammation of the arachnoid, with great 
injection of its vessels. There escaped some serum, which was situ- 
ated between the dura mater and arachnoid. A fibrous tumour of 
the size of a large nut, adhered to the dura mater, under the posterior 
angle of the parietals, and compressed the brain; although the injec- 
tion of the arachnoid was very lively on both sides, it was, however, 
greatest on the left. Hydatid in the choroid plexus, the size of a 
small pea. The water that was between the arachnoid and dura 
mater was more abundant on the left side than on the right ; brain 
pretty soft. General inflammation of the stomach > the S. of the colon 
was of a brownish red. 

"Tim: VII. — Donato Fanti, a collier, act. 50, was brought to the 
hospital of Saint Esprit, in a coinaio.se state, which continued even 
till death. Pulse strong, beating 80 limes in a minute; when the 
extremities were pinched, the patient manifested pain; his skin was 
hot and moisl ; when they opened his eyes, he did not direct them 
to any object. It was impossible to see his tongue, because his jaws 
could not be separated sufficiently. lie only complained of pain 
when he was pressed in the region of the liver, and did not appear 
to suffer any thing when pressed on any other part of the belly. 

"Dissection.— On opening the cranium several ounces of blood 
escaped ; the arachnoid was strongly adherent to the dura mater by 
granulations resulting from old inflammation; the vessels of the brain 
were very much engorged ; on slicing it drops of blood escaped from 
the divided vessels, which reappeared even after wiping. The liver 
blackish; it appeared composed only of black blood, slightly 
gulated, and of cellular bands which alone offered some resistance 



76 INTEEMITTENT FEVER. 

to the finger; where this weak resistance was overcome, the liver 
was but of the consistence of thin jelly ; for the blood appeared 
effused in its tissue, which resembled a pulpy mass. The intestines 
were inflamed in several points, and each inflamed portion corre- 
sponded to some knots of worms which were still alive. The lungs, 
the spleen, and the stomach, were healthy. 

"Case IX. — Joseph Trotti, horse-doctor, of a sanguine bilious 
temperament, strong constitution, was accustomed to go down every 
year to marshy situations, to direct the workmen in seed time, or at the 
harvest, which occasioned obstructions in the spleen and liver. In 
1811, in the time of harvest, being then aged 40, and working with 
great activity, he was affected with an intermittent fever, which con- 
tinued till the third paroxysm. At last he returned home ; the fatigue 
of the journey procured for him a very short sleep. I saw him in 
the fifth paroxysm, when he was in the following state: Agitation ; 
impossibility of finding a position which procured rest; pain under 
the right false ribs, mounting to the top of the shoulder, and extend- 
ing to the left hypochondrium; pains in the articulations ; head heavy; 
tongue covered with a white crust ; bitter taste in the mouth, vomit- 
ing; thirst; face livid; pulse irregular, neither soft nor hard ; great 
difficulty in respiring ; urine red and clouded. He got an injection to 
loosen the belly. He had little repose during the night, for the fever 
returned preceded by a general coldness overall the extremities, and 
the pain in his side was aggravated. 

"6th day. — A frequent dry cough without expectoration. The 
emulsions had eased the thirst. Had no appetite. The bitter taste 
in the mouth had disappeared. A pound of blood was drawn from 
the arm ; the coagulum was almost soft; the serum was livid. At 
the return of the fever, the cold only attacked the extremity of the 
feet. 

"7th day. — The pain worse and worse ; the difficulty of respiring 
still greater ; frequent eructations, urine always the same. As the 
tongue was white, and as he had no stools after the lavement, he took 
§i of manna, which produced a bilious stool. In the night he had no 
sleep ; delirium. 

" He became gradually worse, and died on the 14th day, when in 
the act of raising himself to speak to his confessor. 

"Dissection. — The body offered nothing remarkable but tension of 
the belly. In the abdomen, there was a sanious effusion mixed with 
a little blood. The liver was putrid and tuberculous; this affection 
commenced towards the convex part, extending itself on all sides, 
and descending towards the concave part; nevertheless, the greatest 
destruction was on the convexity ; the rest was engorged and in- 
flamed, its volume was natural. The gall-bladder contained a little 
thin clear bile, not viscid. The inferior face of the diaphragm was 
erysipelatous; the stomach and small intestines were full of water ; 
the spleen double the ordinary size, and of a black colour; the ex- 
terior surface of the right lung was covered with a white crust, the 
inferior part adhered to the pleura costalis. 



INTERMITTENT FEVER. 77 

"Case X. — Dominique de Marco, ast. 30, of a good constitution, 
was affected with a simple tertian fever since the 24th June, 1S22. 
On the evening of the 7th July, he was seized, according to the re- 
port of his parents, with an accession of the pernicious, comatose 
intermittent. He arrived at the hospital on the morning of the 8th 
July, and he was in the following state: Coma; decubitus on the 
back ; face red ; forearms bent and contracted ; pulse 112 ; convulsive 
trembling of the fingers; legs stretched and immovable ; sensibility 
everywhere. They made him swallow three ounces of bark in six 
hours. 

"At 2 o'clock. — Pnlse 100; sinapisms to the feet. 

"9th, in the morning. — He is in a sweat; remission of the fever; 
pulse SS ; a watchful coma; he hears bnt does not answer, although 
he looks; two hours later, pulse 92, very full; several ounces of 
bark. 

"Evening. — Pulse full, strong, 96; profound coma; resisting stiff- 
ness of the right arm; he cannot show his tongue; skin hot, and 
always moist with sweat. To make him swallow the bark, it was 
necessary to pinch his nose, and hold his mouth open with a key ; 
afterwards water was poured in, which he kept in his mouth, and 
finished by rejecting it. He has taken seven ounces of bark through 
the course of the day. 

" 10M, in the morning. — Pulse 140, strong and full ; coma; flac- 
cidity; general immobility; mouth open; blood was taken from the 
jugular ; respiration stertorous. Died towards mid-day. 

" Dissection. — Injection of all the vessels of the arachnoid, even 
to the very smallest ramifications, and on both sides ; but on the right 
side, and upon the anterior lobe, it was of an intense red, without 
any distinction of vessels; when it was torn away from the convul- 
sions the pia mater was also removed ; it adhered so intimately to 
the arachnoid, as to resemble one membrane, red, very thick, and in 
tin: tissue of which blood was effused, which appeared immediately 
to coagulate : little water in the ventricles.; the brain of the ordinary 
consistence : when it was cut there appeared a great number of red 
points, which immediately became the seat of large drops of blood; 
the arachnoid of the cerebellum was also highly injected; the consist- 
ence ol thai organ was natural. Stomach gray, externally, contract- 
ed, slightly inllamed ; small intestines presented two invaginations; 
a portion of this intestine white, transparent, distended with gas; 
the rest may and contracted : in three places all the circumference of 
the tube is red, both within and without, occupying the space of three 
inches in length; all the large intestine is white, &c. Liver gorged 
with blood ; spleen weighed between two and three pounds, and 
reduced into a gray, pulpy state. 

" Case \ I. — Paul Tossini,act. 30, of a good constitution, was taken 
on the morning of the 89th June with a fever, which commenced 
with heat, and which returned every day until the 6th July, when he 
arrived at the hospital. He had had thirst, bloody stools, tenesmus, 
enlarged spleen; and he had taken cooling drinks and a purgative. 
He is now in the following stale: 1 1 is appearance is stupid; somno- 

7* 



78 INTERMITTENT FEVER. 

lence rather than coma; general pain of head. The patient only 
appears to be drowsy, for he is easily awoke, and understands suffi- 
ciently well what is said to him ; decubitus on the back, the knees 
are drawn up, but he cannot extend the thighs without experiencing 
pain ; during his slumbers the right eye is partly open, the left shut; 
it is impossible to depress the lower jaw, without producing suffering; 
the tongue is dry, red, covered with a black crust, which extends 
from the point towards the middle, the breadth of which is not more 
than half an inch; the tongue is drawn a little to the riaht; at inter- 
vals, slight convulsive movements of the hands; pain of belly upon 
pressure; skin hot, dry; pulse 120. When the right arm is extended 
the flexor muscles contract, and the patient seems to suffer much pain; 
but when once extended it continues so. 

"In the night, bloody dejections, extremely fetid; declination of 
the paroxysm, which returned on the 7th in the morning; at seven 
o'clock the patient complained of cold. I did not see him till six 
o'clock in the evening, when the paroxysm was beginning to decline: 
the skin was hot and moist; the lips were encrusted; the pulse was 
not to be felt; respiration hurried; the two forearms bent, when it 
was wished to extend them; above all the right, violent pain was 
produced; preservation of sensibility, everywhere; sometimes the 
right eye a little open, the left being shut. He had several convul- 
sive movements this morning and towards mid-day. He took kino 
before the accession at the moment when he already felt the cold. 
Increase of coma ; died at half-past seven o'clock in the evening. 

" Dissection. — General injection of the arachnoid, particularly that 
part which covers the cerebellum and the lateral part of the com- 
mencement of the spinal marrow. The injection of t lie right side was 
a little more intense than that of the left, although it was otherwise 
as vivid as it is possible to imagine, for it was not a simple injection, 
which merely shows the smallest vessels. The arachnoid was of a 
deep red, as ii'ali its tissue were penetrated with blood. The brain pre- 
sented nothing remarkable. The intestines were injected in the same 
manner, from the ossophagus even to the anus; their whole thickness 
appeared to be impregnated with blood; they were not either thicker 
than natural, nor contracted ; on the contrary, they were distended 
with flatus. Spleen weighed from eight to ten pounds; when it was 
put upon the table, it became flat like a bladder half filled with water; 
its tissue was reduced to a pulp. 

" Case XIII.— Francois Pompei, set. 19, was seized on the 1st July, 
1822, with an accession of fever, in consequence of a sudden chi'll 
which he experienced on entering a cool grotto when his body was 
covered with sweat. He was brought to the hospital on the 2d July, 
at six o'clock in the evening. Before he arrived, he had a consider- 
able epistaxis. He was in the following state : profound coma, eyes 
widely opened, directed to the right, fixed; expression besotted; gene- 
ral immobility; decubitus on the back ; insensibilitvof the extremities 
when pinched ; they were quite flexible. He did not answer the 
questions which were put to him ; the direction of the eyes did not 
change even when one approached him. He manifested pain when 



INTERMITTENT FEVER. 79 

his stomach was compressed ; skin burning hot ; a white cedematous 
swelling of the face; his parents said that this tumefaction had come 
on since the disease, for previously he had rather a thin face. This 
access continued until Wednesday morning the 3d July: he then took 
an ounce and a half of hark. 

"4th July, Thursday morning. — The paroxysm returned, at the 
commencement of which he could still give answers to the ques- 
tions put to him, but the coma went on increasing, and with it all the 
symptoms above described ; the pulse was strong, vibrating, full, 
beating 84; the same direction of the eyes to the right, the same 
immobility of these organs, and of the extremities ; respiration short. 
Eight leeches to the ears ; died at ten o'clock in the evening. 

" Dissection. — Several ounces of blood flowed from the nose in the 
dead-room ; in cutting the scalp, more blood escaped ; the whole might 
have weighed a pound. General engorgement of all the vessels 
which ramify upon the convolutions; the brain still covered by the 
dura mater, gave a feeling which made us believe that there was a 
fluid in the interior, nevertheless there was only a little serosity in 
the ventricles; the substance of the brain was of the natural colour. 
All the intestinal tube, without any exception, presented a red ap- 
pearance, which was owing to a general injection of all the vessels, 
even in their smallest rnmifications. It would be difficult to inject 
so perfectly the vessels either of the intestines or of the mesentery, as 
they were in this body. The intestinal tube, although a little trans- 
parent, was penetrated with this congestion throughout its whole 
thickness; every thing indicated the first stage of a violent inflam- 
mation, that is to say, of a sanguineous congestion. 

"Case XV. — Thomas Adami, get. 20, was brought to the hospital 
on the 23d August, 1S22. He was delirious; they were obliged to 
secure him. After midday, the delirium subsided. A profound and 
intense coma succeeded ; the pulse was strong, hard, and beat S5; 
the extremities were flexible, but motionless; decubitus upon the 
: pupils immovable ; features swollen and intensely hot; general 
insensibility. Body covered with a clammy sweat. In the evening 
the respiration was more hurried, and very much embarrassed; 
pulse not to be felt; froth was discharged from the mouth; he was 
insensible even when his skin was pinched; died at one o'clock in 
the morning. 

" Dissection, eleven hours after death. — General inflammation of 
the arachnoid, of which the very smallest vessels were injected; no 
serosity; the cortical substance was of a deep red, compared with 
that of a subject dead from a shivering fever, (la Jit ore algidc) which 
we shall notice by and by, &c. 

"Case XVI. — Antoine Turiannc, net. 12, of a good constitution, 
was brought t" the hospital on the 23d July, 1822, at four o'clock in 
the afternoon. Ih; was in the following state*; commencement of 
stupor; his answers are slow, and not quite correct j the questions put 
to bun made him discontented ami unhappy; agitation; he turns 
himself on all sides in his bed; eyes open and stupid; skin hot and 



80 INTERMITTENT FEVER. 

dry. (Bled to 8 oz.; lavement ; tisane.) In the evening increase of 
stupor, in consequence of the accession of another paroxysm, coma 
profound, eyes open, pupils contracted and immovable; the fore- 
arms bent upon the arms ; no pain on pressing the belly. Sinapisms 
to the feet. 

"24M July, in the morning. — Continuation of coma; pulse 124; 
head intensely hot ; flexion of the forearm ; it is impossible to depress 
the inferior jaw. Bled at the feet to S oz. In the evening, remission 
of the fever and of the convulsive symptoms; skin slightly moist; it 
was necessary to pinch his nose to make him swallow sij of bark. 

"25th, in the morning. — Return of fever, and the flexion of the 
forearms ; continuation of the stupor; does not reply to questions: 
insensibility of the skin of the legs, that of the arms sensible ; head 
intensely hot; decubitus on the back ; eyes open. Boiling water 
applied twice to the feet; the patient did not feel it very acutely. 
Pediluvium during six minutes ; snow applied to the head ; the pulse 
fell to S2. Return of intelligence ; he swallowed voluntarily the 
bark; but a little afterwards, violent agitation of all the body came 
on : the inferior extremities, which from the commencement were 
cold, were neither heated by the bath, nor inflamed by the application 
of boiling water and sinapisms. Of the four ounces of bark, which 
they made him take, he vomited more than two; neither could he 
retain the bark injections which were exhibited. He remained in 
this state till six o'clock in the evening: the coma returned, and he 
died at 7 o'clock. 

"Dissection. — A very vivid injection of all the arachnoid; be- 
tween its folds there was a membrane produced by the coagulation 
of effused blood ; much scrum between the convolutions, and at the 
base of the cranium; the cortical substance very red. The stomach 
natural; the small intestines contained a prodigious collection of 
worms ; the inflammation was sutliciently intense in this part. The 
colon was contracted, its walls very thick, and the internal membrane 
much inflamed, of a dark red colour. 

" Case XXX.— Joseph Maoloney, set. about 60, came to the hos- 
pital on the 21st Sept. 1822. He had been sick for five days. His 
answers were so confused, it was impossible to find out what had 
been his previous state, further than that he said he had vomited 
some bitter stuff, that he was tormented by thirst, that he had suffered 
great distress, and had pains in the epigastrium. In the evening, 
tongue dry, vividly red round the edges; constipation, nausea with- 
out vomiting, heat natural over the extremities and the thorax ; a 
burning heat in the epigastrium ; anguish ; severe pain in the stomach 
under pressure; pulse small, frequent; lavement of barley water 
— gum water— fomentations to the belly. During the night, vomiting, 
and had a stool. 

"22d, in the morning. — Pulse more expanded; the ideas still con- 
fused, diminution of agitation, heat natural everywhere; tongue dry, 
thirst. Same treatment. About half-past 9 o'clock he had vomited 
the tisane with mucus, bile, and several lumbrici. About half-past 
1 1 o'clock : stupidity; pains in the epigastrium increased. At 3 o'clock 



INTERMITTENT FEVER. 81 

p. m., lancinating pain of belly; pulse small, frequent; extremities 
cold, and bathed in cold, clammy perspiration ; inferior extremities 
bent upon the belly. Bled from the arm ; died in half an hour after- 
wards. 

"Dissection. — Injection of the vessels which ramify upon the con- 
volutions of the brain ; substance of the brain presented an infinite 
number of small drops of blood ; three or four ounces of water at the 
base of the cranium; lungs natural, crepitating. In the belly there 
were fifteen or sixteen ounces of dark blood, running like oil; spleen 
ruptured at its inferior part, not by a fissure as in the other cases, but 
presenting an opening the size of a dollar, out of which came a dark 
and putrilaginous substance ; it was impossible to raise the spleen 
without breaking it, it was so diffluent; it separated in the hand into 
two portions, of which one when placed on the table became flat- 
tened like jelly, and the other portion remained attached to the dia- 
phragm, which they were obliged "to cut to expose the spleen com- 
pletely; it was not much increased in volume. The stomach was of 
a reddish-brown in the greatest part of its extent; inflammation of 
all the rest of the intestinal tube ; rose-coloured within ; bladder 
natural; liver gorged with blood. 

"Case XXXVIII.— Angelo Galetti, set. 18, of a good constitution, 
was brought to the hospital on the evening of the 29th July. The 
patients who were near him said, that during the night, he com- 
plained continually of sharp pains in the belly. Took an ounce of 
bark; the whole of the body was as cold as ice. 

" 30/A, S a. m. — Legs, thighs, forearms, arms, cheeks, of an icy 
coldness; the belly, chest and forehead were of rather a lower tem- 
perature than other parts of the body; pulse insensible at the wrists; 
I could feel it but very feebly in the crural arteries; it beat 100; the 
patient trembled and complained continually; his most common po- 
sition was on the left side, with the thighs bent on the belly. He 
Understood what questions were put to him, but not sufficiently well 
to -ive proper answers; he never entered into any detail ; and died 
at ha If- past nine. 

"Examination three hours after death. — The small intestines 
slightly distended with gas, were externally of a purplish red. The 
internal membrane was of the same colour, so that the violent injec- 
tion of winch they were the seat, had existed throughout the whole 
thickness of the substance of the intestine. This injection was recent. 
Inflammation of the upper half of the cnccum. The whole of the 
gnat intestine was white externally; on being opened, it presented 
an inflammation, the violence of which was greater towards the rec- 
tum, where the mucous membrane was so intensely inflamed, that 
some blood h.ul been effused, which, mixing with the mucus, formed 
a thick- coating, which adhered to the whole of its surface. The 
colour of all the interior of the' Colon, and especially of the rectum, 
waMii a lively intense red: in ;i word, the most violent degree of 
inflammation that can exist without disorganization. The stomach 
was pale : after being washed, ii presented, near the pyloric extre- 
mity, an infinity of little depressions, from half a line to a line in 



82 INTERMITTENr FEVER. 

diameter, and some of which contained in their bottom a small spot 
of blood, which was easily removed. The folds of the mucous mem- 
brane were, besides, nearer each other, and more numerous than 
ordinary. The mucous coat itself was thickened. The liver was 
healthy. The spleen large and pretty hard, but of a redness of the 
lees of wine. Slight adhesions of the right lung; the same between 
the whole surface of the heart and pericardium ; they were easily 
destroyed. Injection of the arachnoid, engorgement of the vessels 
which ramify on the convolutions, and of those which compose the 
choroid plexus. 

"Case XXXIX.— Vincent Crescenzi, aet. 60, of a thin but healthy 
habit of body, fell sick on the 19th August, 1822. He was attacked 
with fever, which set in with shiverings, followed by extreme heat, 
pain in the head and belly, vomiting of bilious matter. During the 
night, the paroxysm terminated in sweating. He was brought to the 
hospital of Saint Esprit on the 19th August, 1S22. The fever re- 
turned in the morning, preceded likewise by shiverings, and accom- 
panied by the same symptoms as in the evening; the stomach was 
painful on pressure; the patient experienced a great heat in the 
inside; anxiety; depressed countenance; the features were as if flat- 
tened to the bones of the face; the colour of the face was natural, 
the expression dull. (Half an ounce of bark on the decline of the 
paroxysm.) 

" Evening. — Decline of the symptoms; skin wet with a cold clam- 
my sweat ; pulse small, frequent ; general shivering ; pain at the 
epigastrium; tongue red, but moist; no thirst. (Half an ounce of 
bark.) 

"Night. — The skin remains moist and cool. The patient has 
vomited the bark. 

" He had several paroxysms afterwards ; became worse, and died 
on the night of the 23d, sensible to the last. 

" Dissection. — Slight injection of the arachnoid; engorgement of the 
vessels which ramify upon the convolutions ; an effusion of yellowish 
serum between the foldings of the arachnoid; cerebrum and cere- 
bellum natural ; heart and lungs healthy. Stomach gray externally 
and contracted. Inner surface of a bright red, deeper still towards 
the pylorus. Foldings of the mucous membrane better marked than 
usual. Small intestines gray externally and contracted. Internally 
their redness was brighter than that of the abdominal muscles, which 
afforded us a point of comparison. To give an idea of this inflam- 
mation, the colour of the large intestines could be compared to that 
which they would receive were they soaked in black blood. This 
inflammation increased as it approached the S. and the rectum ; liver 
healthy; spleen of a middling consistence, between the state of de- 
generation and health. This inflammation could be compared only 
to that of the 30th case. 

" Case XL. — Vincent Cola Paolo, of Rimini, set. 40, of a good 
constitution, residing at Roma Vecchia, entered the hospital on 7th 
July. Had been attacked with a paroxysm of fever on the previous 



INTERMITTENT FEVER. 83 

evening. On the morning of the 7th, his state was the following: — 
Hands colder than those of a dead person ; pulse 108, small, con- 
tracted ; hiccup regular in its returns fourteen times in the minute; 
position supine; sighs drawn easily; answers pretty correctly; he 
experiences pain in the region of the liver. In the evening, the fit 
declined, and the hiccup disappeared. 

" On the morning of the Sth, senses completely restored, with his 
natural expression, which, during the paroxysm, assumed that par- 
ticular aspect which characterizes those labouring under the fever; 
but the hands have always an icy coldness which extends halfway 
up the forearm ; he is not aware of their being cold; but on placing 
them on his belly, he at once becomes sensible of it ; he speaks as if 
he were in a state of health. At nine o'clock, his appearance became 
as if besotted; he replied with hesitation and reluctance. Hasan 
inclination to sigh. He lay on the side, with the legs bent upon the 
abdomen ; the fit commenced, the cold gained upon the trunk, re- 
spiration became short, some tendency to hiccup ; in short, he died at 
three in the afternoon. He took some bark during the apyrexia. 

" Dissection. — General injection of the arachnoid ; which is thicker 
than natural, red, and as if doubled by a sanguinolent false membrane; 
the vessels distributed upon the circumvolutions of the brain are en- 
gorged ; the stomach is much inflamed in its pyloric half, the rest of 
the intestinal canal healthy. 

"Case XLI. — Angelo Donni, of Milan, set. 35, weak, lymphatic 
constitution ; preparer of macaroni. On the 5th July, 1822, he en- 
tered one of the grottos of Monte Testaccio, when he experienced a 
general sense of cold, which he attempted to shake off by drinking 
seven or eight glasses of wine; but could not, however, warm him- 
self. He then felt a great weakness, which was the predominant 
symptom during the six days previous to his entering the hospital. 
His state had so little of a decided febrile character, that according 
to his account, the medical men could not tell him if he had had the 
fever. II" had a sense of general uneasiness; took an emetic and a 
purgative, and returned to his work; but the general state of disease 
ami une tsiness increasing, as likewise the weakness, on the 11th of 
July, in ili" morning, he came to the hospital of Saint Esprit, on foot, 
supported by a man on each side. Being arrived in the 1st ward, 
where I first saw him, he seated himself upon a form, and appeared 
il ill. He let himself fall down upon the right side, but the ex- 
pression of Ins countenance was not that of a person fainting. There 
was something in the motions of his head, of his eyes, resembling 
those symptoms produced by drunkenness, and not that want of 
pou-i r occasioned by the cessation of the motions of the heart. He was 
merely supported, and recovered, and he was then, enabled to ascend 
more than thirty steps, in orderto reach the clinical ward. When in 
bed, the following was his condition ; pulse frequent, weak ; tempera- 
ture of thighs, legs, hands, and arms, cold ; tongue moist and not red. 
II<' was able to give a history of his previous state, nevertheless, he 
begged the physician to question Ins companion, who accompanied 
him to the hospital, for although he had neither delirium nor coma, 



84 INTERMITTENT FEVER. 

nor syncope, he appeared so confused, so little master of his ideas 
that he declined to give any account of it. All he assured-us of was, 
that he had never had the fever. In the afternoon he was twice ill. 

"Evening. — Pulse scarcely perceptible, great pains, extremities 
cold, the left hand more so than the right; it is of a livid colour. 
Temperature of the belly, and the chest, almost natural ; face pale, 
delirium, agitation, inquietude. (Decoction of bark 3viij. Extract 
of bark, theriaque, aa 3ij. Laud. liq. anod. camph. emuls. aa gr. 
xx. blisters to the thighs) 

" 12th July. — At half past one in the morning, sweat general and 
copious, but cold. In the morning at the visit, weakness the same; 
pulse insensible at the arms, which are cold, as also the thighs; the 
belly is a little warmer, but it is also below the natural temperature; 
pulse at the temples 1 14. The blistered surface pale, no water under 
the epidermis, which remains only detached. He has lost no part of 
his judgment, but manifests a tendency to drowsiness; complains of 
no pain; the belly is not tender on pressure; the principal ailment is 
great weakness. (Blisters to the arms. Bark sij in wine.) 

"A little later, return of the same symptoms, alternating with 
delirium and drowsiness; general and intense sense of cold ; died at 
half-past five in the afternoon. 

"Half an hour after his death, the body was warmer than dur- 
ing life. 

"Dissection. — Stomach highly inflamed between its great cur- 
vature and the pyloris. Intestines presenting traces of inflammation 
in some parts. Spleen soft and pulpy, liver healthy, old adhesions 
of right lung. Before opening the cranium, the head was separated 
from the trunk, when there escaped by the occipital foramen a great 
quantity of bloody serum. Injection of the arachnoid in its minut- 
est ramifications, but a little more on the left than on the right side. 
Great engorgement of the vessels distributed on the circumvolutions, 
more marked on the leftside. Gray substance of the brain, of a pale, 
rather than of a deep hue ; choroid plexus pale; serosity between the 
circumvolutions; brain of a soft consistence." 

From these and other cases it appears, that M. Bailly found in 
thirty-three dissections, more or less extensive disease in the brain: 
in twenty-two of these there were thickening, and other mark's of 
inflammation, in the arachnoid coat; and in eleven, inflammation of 
the substance of the brain. In twenty cases there was gastro- 
enteritis. In four cases gastritis by itself, and also four of enteritis, 
uncomplicated with gastritis. In eleven the spleen was softened; 
in some instances enlarged; one weighed from two to three pounds, 
and another from eight to ten pounds. In two cases the spleen was 
large and hardened. In three cases the spleen was ruptured, and in 
one it was gorged with blood. In two cases the liver was softened; 
in four gorged with blood ; and in one case the gall-bladder was 
inflamed. In two cases there was pericarditis. In three, peritonitis. 
In one, pneumonitis. In one case there were inflammation and 
enlargement of parotid. 

These statements respecting the appearances on dissection in in- 



INTERMITTENT FEVER. 85 

termittent fever, will be found fully corroborated in the works of 
Morgagni, Pringle, Cleghorn, Chisholm, and Fellowes. 

Causes of Intermit tents. 

In point of form, I ought now to treat of the causes of intermittent 
fever, but having explained myself so fully on this subject, when 
treating of the causes of fever in general, at page 56, it is unneces- 
sary to do so in this place, further than to repeat my conviction, that 
the effects of internal irritations, sudden variations of temperature, 
and of evaporation, as causes producing intermittents, have hitherto 
been too much overlooked. 



Pathology of Intermittents. 

As there are three distinct stages in this disease, it will be proper 
to treat of the pathological condition of the body during each. 

Cold stage. — Perhaps the first link in the chain of morbid action 
may be in the nervous system; there is decided evidence of its being 
involved from the beginning to the termination of the disease. But 
as there is nothing to guide us in the investigation, I shall not enter 
into it. The first circumstance which we distinctly perceive, is dimi- 
nished circulation of blood in the extremities, then a sense of cold- 
ness, and with it a feeling of weakness. These are evidences of an 
irregular determination of blood, by whatever cause produced; and 
in proportion as blood accumulates in the vessels of internal organs,* 
their functions become impeded. The lungs show their gorged state, 
by the short, difficult, and anxious breathing; by the impossibility 
of inflating them beyond the least degree; and by the violent dry 
cough which occasionally takes place. The livid appearance of the 
cheeks, lips, and mucous membrane of the mouth, is an additional 
proof of the embarrassed state of the lungs, showing that the blood 
is not properly decarbonized. The disordered functions of the brain 
in this stage, depend, I imagine, principally upon the gorged state 
of the lungs, and also upon the overloaded state of the right side 
of the heart, preventing the free return of blood from the head. 
The disordered functions of the brain may also be produced by a 
change in the balance of the circulation of the vessels of the head, 
independently of the state of the lungs and heart. The tremors may 
probably be attributed to an accumulation of blood in the vessels of 
the brain and spinal marrow. The sense of cold seems to be owing 
partly to the state of the nervous system, and partly to the state of 
the lungs. The pain in the head and loins, and oppression at the 
praicordia, may be fairly attributed to the same causes. The mus- 
cular prostration, and feeling of sinking, are not owing to actual 
debility, but to obstructed action, in consequence of the above-men- 

• This is (he state termed congestion, which implies, that the balance between the 
ariiTi;ii and renona mmi-mis i- deranged for the time, ibe latter being overloaded 
it congested with blood; and doi thai the circulation in any organ, or set of organs, 
is entirety obftlrocied : which, nevertheless, does actually happen in those extreme 

hi which reaction does not take place, and the individuals die in the cold 
stage. 

B 



86 INTERMITTENT FEVER. 

tioned condition of organs. The proof of all which circumstances 
is to be found in the fact, now well known, that abstracting blood, 
in the cold stage, will immediately remove not only the difficulty of 
breathing, the pain in the head and loins, the disordered functions 
of the brain, (when these exist,) the oppression at the praecordia, &c, 
but will also stop the rigors, restore the strength of the pulse, increase 
the heat of the whole body, and cause the sensation of cold to vanish 
in an instant. Cullen and others believed, that all the subsequent 
phenomena of fever depend upon the cold stage, which, although a 
mere hypothesis, is now for the first time proved to be true. 

The pathological views which are still taught in most of the schools 
of Great Britain may now be stated, and this shall be done in the 
words of the late very celebrated professor of physic, Dr. Gregory: 
"The languor and debility depend upon diminished nervous energy : 
the uneasy feelings, on muscular debility; the paleness of the face 
and extremities, and shrinking of the features, are owing to spasms 
of the extreme vessels; the coldness is to be explained by the blood 
being propelled from the surface by debility, or prevented from 
entering the vessels by the spasm ; thus the cold may be produced 
either by the spasm or by the debility ; the tremors depend upon 
debility of the muscles, but there is also some irregularity of nervous 
energy; the breathing during the cold stage is small, frequent, and 
anxious, owing to debility of all the muscles that serve for respira- 
tion, while, at the same time, the congestion of blood produced by 
the weakened action of the heart, would require the breathing to be 
often repeated, and the respirations to be fuller than natural, which 
circumstance tends to increase the uneasiness; the heart partakes 
also of the debility; this debility of the heart produces an accumula- 
tion of blood in the great vessels, and this occasions that unusual 
motion of the organs of respiration, termed yawning. Want of 
appetite, nausea, and vomiting, are owing to debility of the fibres of 
the stomach. Costiveness is produced partly by spasms. Failure of 
attention and memory, and also delirium, are owing to debility." 

On perusing these statements, the reader will observe sufficient 
proof of the pathological condition of the body which I have de- 
scribed, but instead of attributing it to the same state of organs, he 
places spasm and debility as the cause of each phenomenon ; thus 
most unphilosophically, like the rest of the disciples of the Cullenian 
school, he makes the facts to suit the doctrines. Influenced, as this 
distinguished man's mind was, by such erroneous pathology, it is no 
wonder that he should have pronounced the following dogma: u I 
have no doubt, therefore," said he, " that the causes producing fever 
act first by inducing debility; and accordingly we find, that stimu- 
lants employed at this period have produced good effects in checking 
this disease, while evacuations, as blood-letting, which at another 
period of the disease, might have been proper, if employed in the 
first stage, never fail to be attended with most dangerous conse- 
quences; or it is, to use the words of Celsus, i hominemjugulare. ,,> 

I shall now show that this is a statement which Celsus never made 
with reference to the cold stage of intermittent. On a careful refer- 
ence, I find no allusion made to such a practice in his works ; but in 



INTERMITTENT FEVER. 87 

treating of the danger of bleeding in vehement fevers, he expresses 
himself thus — " Quod si vehemens febris urget, in ipso impetu ejus 
sanguinem mittere hominem jugulare est." — Lib. ii. cap. 10. It 
appears to me that Dr. Gregory was led into this error by a state- 
ment made by Sir John Pringle, who, in allusion to the good effects 
of bleeding in the camp fever which he describes, observes, on page 
210, (Observations on Diseases of the Army, ed. 1768,) "A person 
unacquainted with the nature of this disorder, and attending chiefly 
to the paroxysms and remissions, would be apt to omit this evacua- 
tion, and to give the bark prematurely, which might bring on a con- 
tinued inflammatory fever. A vein may be safely opened either 
during the remission or in the height of the paroxysm ; for besides 
that I have observed the remission to come sooner and fuller after 
hemorrhage, I have repeated experience of the safety of bleeding in 
the hot Jits; and not only in this, but in the marsh fever, even after 
it had come to almost regular intermissions. In order to make Cel- 
sus's maxim (he quotes the above passage from lib. ii. cap. 10,) con- 
sistent with this practice, we must interpret his term impetus febris 
in the sense of this chilliness or cold lit which preceded the hot one 
in the fevers which he describes,ybr then, indeed, bleeding ivould be 
improper.'' This is straining an author's statement to suit other 
views with a vengeance ! The meaning of Celsus is clear and pre- 
cise — he makes no allusion to the cold stage. Does not this show 
how liable we are to be misled by the authority of a name? 

Hot stage. — Acting upon the principle of not inquiring into occult 
causes, very little need be said respecting the circumstances which 
produce the reaction ; but there has long existed a pretty general 
belief that the blood accumulated about the heart, in the cold stage, 
proves a stimulus to that organ, and produces reaction. In this man- 
ner Dr. Gregory and others make the spasm of the extreme vessels 
the cause of the diminution of blood on the surface ; and then he 
observes — "The blood thus driven upon the internal parts, must ac- 
cumulate in, and prove a stimulus to, the heart and great vessels." 

The next question comes to be, how is this effected? The truth 
is, that we know nothing of the matter; and, after all, it is perhaps 
best to attribute it to " the principles of life;" or, in the language of 
Cullen, to " via medicatrisc naturae" which is ever in action, to pre- 
vent injury, and to remedy the evil after it has occurred. The phe- 
DOmena which are ascribed to the state of reaction, are those, the 
combination . <>J 'which is denominated fever; namely, hot and dry 
skin; quick pulse; thirst and loss of appetite ; restlessness and anxi- 
ety; headache, and occasionally delirium ; hurried respiration ; dry, 
tarred tongue, &c. 

With respect to the heat and dryness of the skin, the old opinion of 
Boerhaavc need scarcely be alluded to, who attributed this condition 
to the friction of the globules of the blood against the sides of the 
vessels; neither is it necessary to dwell upon the still older opinion, 
which attributed the heat to fermentation ; nor is it requisite, after 
what has been previously stated in this v/ork, to say a word more 
respecting spasm of the extreme vessels. The heat and dryness of 
the skin in the second stage of intermittent are, no doubt, owing 



88 [INTERMITTENT FEVER] 

partly to the suppression of the secretions and excretions; also, proba- 
bly, to some change in the nervous system, but principally to the in- 
creased quantity of blood driven lo the surface of the body. 

Sweating stage.— It has been stated, that, in cases in which no 
organic lesion exists, the pains and uneasy feelings begin to subside 
after the commencement of the sweating, and soon afterwards dis- 
appear. An interesting question here presents itself, How does the 
perspiration produce the effect ? It appears to me that it acts in two 
ways ; first, cooling the body by evaporation •, and secondly, it 
moderates the force and frequency of the heart's action, by depleting 
the system. It is impossible to state the precise quantity of fluid per- 
spired in such cases ; but, if I can trust the hasty, and far from ac- 
curate observations made respecting this point, by placing oil skin on 
the outside of the bed-clothes, I am inclined to believe that it amounts 
to considerably more than two pounds; and it must be kept in view, 
that this discharge comes directly from the blood itself. 

[The pathology of intermittent fever has ever been a vexed ques- 
tion in medicine, nor shall we attempt to solve it; at the same time, 
we propose to give a brief view of those modern doctrines, which, 
originating with the French pathologists, have been more or less 
adopted wherever medicine is cultivated. 

The physiological school apply their idea of irritation, somewhat 
modified, however, to explain the phenomena of intermittent fever. 
The fundamental principle to be established is, that irritation can 
admit of total disappearance for a longer or shorter period, and then 
return at stated intervals with its previous intensity, leading finally, 
to alteration of the tissues of organs. It is contended that periodicity 
is natural to a state of health ; that the activity, and consequent 
functional energy of many of the organs, are not constant, but 
roused at certain periods, while during the intervals they are in a 
state of comparative repose; thus the brain has its waking and 
sleeping hours ; the stomach digests its food, and becomes quiescent; 
even the heart and lungs undergo diminution of energy. But there 
are more marked periodical occurrences, as the menses, hemorrhoidal 
fluxes, &c, which give both force and plausibility to this position. 
On referring to the modification of irritation by the tissue in which 
it is located, it will be found that in those which are so anatomically 
constructed that it can easily be produced, and as rapidly removed, 
periodical irritations are universally seated. Such tissues possess a 
looseness of structure, and abound with nervous filaments and blood- 
vessels. Those which are low in the scale of vital activity, which 
are closely allied to the osseous structure, and which, when once 
diseased, go through long and protracted changes, are not affected by 
periodical irritation. The tissues, then, in which this form of deranged 
organic action is manifested, are those which possess the highest 
degree of vital activity, as the brain, mucous membranes, and the 
hollow viscera. For reasons analogous to those which induced 
Broussais to locate the primary irritation of continued fever in the 
stomach and intestines, he is led to maintain that the primary seat 
of intermittent fever, is in the same viscera; and without searching 
for the cause of periodicity, is satisfied of its existence as a fact. 



[INTERMITTENT FEVER.] 89 

Intermittent fever, therefore, is regarded by him as gastro-enteritis 
running through its stages in a limited time, and terminating by a 
translation of irritation to the skin, inducing profuse perspiration ; 
thus constituting a true crisis* The phenomena of the paroxysm 
are accounted for in the same manner as those of fever generally, 
some of the preliminary symptoms being referable to the organ 
primarily affected, the others to sympathetic disturbances. In pro- 
portion as the first is intensely affected, will the symptoms be acute, 
and the sympathies called into action, giving rise to attacks of greater 
or less violence. If any one of the vital organs be so much deranged 
as to threaten life, as, for instance, the brain or lungs, a form of dis- 
ease appears which is termed pernicious intermittent; or if attended 
with putrid or adynamic symptoms, it is called malignant inter- 
mittent. Intercurrent intermittent and remittents are only shades 
of the same disease; the irritation subsiding at intervals, but not 
totally disappearing, and then again occurring with fresh energy, 
changing the type of the fever, but not its essential character. Con- 
gestion in important internal organs, is the most formidable attendant 
upon these intermittent irritations; the blood is so forcibly, and in 
such quantity determined to them, as to suspend their functions, or 
even to destroy them in debilitated persons, or in those who are 
prone to irritation. This effect is what is designated by the " lost 
balance of the circulation;" and means nothing more than diminution 
of excitement, and anasmia of external organs, while an irresistible 
attraction of fluid exists in the central. The analogy between con- 
tinued and intermittent fever, (the latter being regarded as identical 
in nature with the preceding, only running its course in a shorter 
time,) is strikingly demonstrated by the easy transition of one into 
the other. Thus, by stimulating a patient labouring under the aggra- 
vated symptoms of intermittent, the periodical irritation can be con- 
verted into continued ; and frequently the continued form may, by 
soothing measures, be made to assume a partial and even perfect 
periodicity. The irritation being disturbed, the transfer to the skin, 
or crisis, will be imperfect; which is another cause of prolonged 
irritation, and change to the continued form. Hemorrhagic and 
neuralgic irritations sometimes assume an intermittent character; 
hence the close affinity noticed by authors, between them and inter- 
mittent fever. M. Broussais endeavours to confirm his reasons for 
establishing ihe primum mobile in the stomach and bowels, by 
reference to the different organic lesions which are found to ensue 
from protracted attacks : as, chronic inflammations of the mucouscoat 
of the Btomach, with thickening and alteration of texture; enlarge- 
ment of the liver with alteration of function leading to jaundice; dis- 
ordered digestion, and its concomitant evils • and enormous increase 
of the spleen, vulgarly denominated ague cake ; these all result from 
thru form of irritation constituting inflammation. 

ML Roche has thrown out some ingenious reflections upon the 

• ("Knrli ro^iilnr attack of intermittent fever is the rign <>! I irnstro-enteritis, the 
Irritation of which i-^ transferred t<> the cutaneoni exhalents, producing a crisis ; if 
the ii ritaiion is n<>i completely displaced, the fever i> remittent ; if it ceases to remove 
at nil, it becomes continued." — Exanvn <U» Doetrinei Medicates.] 

8« 



90 [INTERMITTENT FEVER.] 

disease which at present occupies ns. He contends that fevers 
cannot assume the intermittent type, unless the causes are of the 
same periodical character; and upon an examination of them, it 
will be perceived, that they are intermittent in duration. Intermit- 
tents most generally abound in the spring and autumn. Now it will 
be acknowledged that, during these seasons, there is the most marked 
difference between the temperature of the day and night, and con- 
sequently, at short intervals of a few hours, an alteration of action 
and reaction takes place in the human frame, which soon may be 
converted into habit. 

The impression of marshy exhalations is precluded during the day, 
in consequence of their being diffused and dispersed into the upper 
atmosphere by the effect of solar heat : but as soon as the effect of 
this is removed, the upper strata are condensed and precipitated in a 
concentrated form, so as to have acquired peculiar violence ; when, 
coming in contact with the skin and mucous membranes, they are 
absorbed, and produce the phenomena which constitute an accession 
of intermittent fever. If the action of marsh miasmata be inter- 
mittent, it is not astonishing, that the malady which is produced by 
them is equally so. According to this author, the accession of the 
paroxysms is repeated by virtue of a tendency of our organs to re- 
produce certain acts which once had taken place, even when the 
cause first provoking them had ceased to operate. Very frequently 
the repetition of a paroxysm does not occur, in consequence of a 
withdrawal of the causes; this is countenanced by the fact, that 
removal from an infected district cures the disease in numerous 
instances. 

M. Braehet has paid some attention to the phenomena of inter- 
mittents. Basing his theory upon the peculiar views which he takes 
of the offices and connections of the two nervous systems, the cere- 
brospinal and ganglionic, he attributes the primary lesion to their 
derangement, to the exclusion of irritation as understood by the 
physiological school. The ganglionic system presides over all the 
actions of organic life, as nutrition, secretion, &c; while the nervous 
system of relation has charge of the connection with the exterior 
world. According to him, the phenomena of intermittent fever, are 
such as can only be produced by derangement of the healthful influ- 
ence of the first communicated to the second ; and no matter whether 
the modifying impression is made externally by atmospheric or 
physical agents, or takes place internally by marsh miasm, the first 
effect is produced on the nerves of the organic movements. That the 
result of this impression is not inflammation, he proves by the fol- 
lowing experiments. Towards the end of October, 1S22, he took 
for seven nights in succession, at midnight, a cold bath in the river 
Saone. The first bath was of a quarter of an hour's continuance; 
the second half an hour; from this he went on protracting the time, 
until he was enabled to remain in the water a whole hour. After 
each bath, he laid down in a warm bed, and underwent considerable 
reaction, with increased warmth, followed by profuse sweating ; after 
which he went to sleep. At the expiration of seven days, M. Bra- 
chet omitted his experiments; but was surprised to find, during the 



[INTERMITTENT FEVER.] 91 

following day, that between twelve and one o'clock p. m., all the 
attendants of a true intermittent paroxysm made their appearance. 
As he experienced no inconvenience during the interval, he allowed 
this artificial fever to proceed, and experienced six distinct attacks. 
Upon the seventh night following the last bath, he was called upon 
to ride some distance upon professional business, a short time prior 
to the expected invasion ; the exercise thus taken produced excite- 
ment of his system, which was kept up by placing himself near a 
large fire, and from that time no accession reappeared. This account 
corroborates, in a measure, the statement of M. Roche, that inter- 
mittence of cause will produce a habit, more or less difficult to coun- 
teract, in proportion to its fixedness. In speaking of these conclu- 
sions of M. Brachet, it is understood that the paroxysm is simple in 
character, and unaffected by organic lesions which would modify its 
type, and be productive of such complications as are found in these 
fevers of serious grade. 

Malignant intermittents assume forms which are characterized by 
acute symptoms, arising from serious lesion of some particular organ. 
If it be the brain, there will exist phrenitis, apoplexy, &c. If the 
heart, the various manifestations of cardiac disease; if the liver, he- 
patic derangement ; if the lower bowels, dysentery may be the com- 
plicating attendant. The danger of these different complications is, 
of course, measured by the importance of the organ and the force of 
the attack.] 

Treatment of Intermittents. 

It was formerly a matter of high dispute among physicians, whether 
an intermittent fever ought to be immediately cured, or allowed to 
run its course. Many believed that the system is benefited by the 
disease — that the febrile symptoms, in fact, are the natural cure of 
some other disorder in the constitution — and they argue that curing 
it must be hurtful. Some still assert that the disease will cure itself; 
and therefore, that it is improper to apply any remedies, except laxa- 
tives, to keep the bowels open. 

Tin; lust maxim in physic is, to get rid of diseased action as 
quickly as possible, as there is no saying what mischief is to follow 
in the train of consequences. "There could not be a moment's hesi- 
tation," says Dr. Fordyce, "in determining to restore the patient to 
perfect health at once, were there any remedy or mode of treatment 
that would certainly prevent the returns of the paroxysms of a tertian 
intermittent, and take off the symptoms remaining after the crisis, 
so that no other disease should follow. But there most undoubtedly 
is no medicine uniformly efficacious, or that always leaves the patient 
in tolerable health, and secure of not being destroyed by the remains 
of the disease, or by any other disorder arising in consequence of 
it." — "Were there any such, why should different practitioners 
attach themselves to particular varieties of bark; recommending the 
brown, the yellow, or the red, with such decided preference? Why 
should they prefer arsenic or zinc, if any one were uniformly suc- 
cessful ?" 



92 [INTERMITTENT FEVER.] 

The discovery of such a remedy has always been a great deside- 
ratum; and although no one remedy has yet been found out, I believe 
bleeding, in the cold stage, conjoined with laxatives, and the occa- 
sional use of the sulphate of quinine, to be as certain a mode of 
treating intermittents, as any other set of remedies can be said to be 
certain in the treatment of any other class of diseases. 

Treatment in the cold stage. — As the cold stage demands differ- 
ent management from the hot, and both of these from the sweating 
stage, and all these from the intervals between the paroxysms, I shall 
treat of the means to be used in each stage, and then describe the 
plan which ought to be adopted in the intervals, to prevent a return 
of the complaint. In the cold stage, which generally lasts from half 
an hour to two or three hours, the first thing to be done is to endea- 
vour, by every means in our power, to restore the heat of the body, 
and to relieve uneasy feelings, with a view to shorten its duration, 
and bring about reaction. Hot applications; additional bed-clothes; 
warm drinks; stimulants; opiates and aether, have been strongly 
recommended — with how little success, every experienced man can 
testify. The best method of applying heat is, to surround the patient 
with bottles filled with hot water; and it affords considerable relief, 
when a sufficient degree of heat can be applied to the epigastric 
region. It appears to be more efficacious than the general warm 
bath, in which I have seen the patient shiver, and complain loudly 
of cold, when the bath was heated above 100°. It is a common plan 
to give a bumper of gin or brandy, with some pepper to create reac- 
tion, and cut short the cold stage; and there can be no doubt that it 
has sometimes succeeded; but I have seen much injury ensue in 
many cases. This enables us to account for the horror entertained 
by the older writers, at cutting short the cold fit, because it was never 
attempted by any other means than by ardent spirits, large doses of 
opium, and aether. Dr. Gregory used to mention, in his lectures, two 
cases of violent epistaxis, succeeding to doses of brandy and pepper, 
which reduced the patients to great weakness. In the instances 
which fell under my own observation, and to which I have already 
alluded, fever and violent cerebral symptoms succeeded, and in two 
or three instances, local inflammations. 

[Opium is sometimes given with decided effect to arrest the cold 
stage of intermittents. The usual method is to administer thirty 
drops of laudanum in a tumbler of hot lemonade, and if the desired 
result is not obtained in a quarter of an hour, give half the quantity 
in the same medium. The ague is in most instances, speedily ar- 
rested, sometimes in a few minutes, and followed by the hot stage, 
which latter is rendered shorter and more tolerable by the opiate 
treatment. 

Emetics also assist in abridging both the duration and severity of 
agues, nor is there any objection to the use of ipecacuanha or mus- 
tard for this purpose. There is often a disposition to vomiting; and 
by promoting it, the stomach may be relieved of undigested food or 
irritating secretions, and becomes better prepared for the reception 
of curative remedies at the close of the paroxysm.] 

Bleeding, in the cold stage, will, in a great majority of instances, cut 



INTERMITTENT FEVER. 93 

it short ; in fact, it will rarely fail in stopping the existing paroxysm, 
and, on many occasions, it has prevented a return of the disease 
to which the patients had been long subject, and by which they 
were nearly worn out. It is difficult to determine what quantity of 
blood it will be necessary to draw in any given case; sometimes it 
requires twenty-four ounces; I have known three ounces suffice, 
and, in one case, an ounce and a half produced the full effect. The 
larger the orifice in the vein, the greater is the chance of arresting 
the disease at a small expense of blood; but, in many cases, the 
operation is attended with considerable difficulty, from the convul- 
sive tremors which affect the whole body. I was once successful in 
arresting the disease by bleeding, in a cold stage which had continued, 
twenty-six hours ; but I regard this as an extreme case. The blood 
sometimes only trickles down the arm ; and, as the system is relieved, 
the stream becomes larger and stronger, til! at last it springs from the 
orifice, and frequently before six ounces are taken, the patient will 
express relief from violent pain in the head and loins, and it will soon 
be observed that he breathes more freely. The tremors become 
slighter and slighter, and, by the time a few more ounces are ab- 
stracted, they will cease altogether, and with them will vanish the 
painful sensation of cold. The pulse will be found stronger, and a 
gentle moisture will be observed on the body. If the patient be pro- 
perly managed with respect to bed-clothes, neither hot nor sweating 
stage will in general follow. Most of the patients who have been 
treated by myself, or by my pupils under my immediate inspection, 
have fallen asleep immediately after the operation; but some have 
even got up and dressed themselves.* 

I wish to impress upon the minds of my readers, that by venesec- 
tion in the cold stage of intermittents, we stand upon vantage ground, 
by affording our patients the benefit of the following circumstances. 

1*/, The injury which in many cases results from the continuance 
of the venous engorgement, which so constantly leads to organic dis- 
is avoided. 

2d, The danger proceeding either from the want of sufficient re- 
BCtion, or from its excess, is also avoided. 

3d, The practice prevents debility, in a direct manner, by saving 
the vital Quid, as well as by materially shortening the duration of the 
diseased action. 

■J///, The chaiice of a return of a paroxysm is diminished; or if it 
should recur, the force of the attack will in general be weakened; 
and in that case a most important point will be gained, by affording 
an opportunity for the administration of other remedies, as bark or 
arsenic, which might previously have been exhibited in vain. 

5/A, Experience has also taught me, that bleeding in the cold stage 

• [The aathor, In support of his views of ihe advantage and importance of bleed- 
ing in ihe cold-stage ol intermittent fevers, has given a condensed history of nume- 

ireated in this way, Im'Ii in Km ope and in India. Tboqgh these cases 

are published in "nr la I American edition, we have thought it unnecessary to re- 
print then on the present occasion, inasmuch as the author's vjews are sufficiently 
elucidated without them; and also because the treatment in question, however ap- 
propriate in the apoplectic <>r congested state of vital organs, is Seldom requisite in 

ibfl management of the common forms of intermittent lever in this country.] 



94 INTERMITTENT FEVER. 

is far more efficacious than bleeding during the hot stage, or in the 
intervals. Several cases are quoted, in which bleeding was had re- 
course to in the hot stage to moderate threatening symptoms, but 
without preventing a return of the disease at the regular period ; and 
in these same instances, bleeding in a subsequent cold fit, had the 
effect, not only of stopping the existing paroxysm, but of preventing 
its return. 

If any other evidence were wanting to show the advantage of a 
radical change in the treatment of intermittent fevers, it will be 
readily found by contemplating the results which befell one of the 
finest armies Great Britain ever sent from her shores, and which 
went to Walcheren on the 5th July, 1809. The prevailing disease 
was intermittent fever, and in the course of six weeks, 8000 sick 
were sent to England, and 3000 more soon followed. While only- 
seven officers and ninety-nine men were killed in action during the 
whole campaign, we find that forty officers and 2041 men died from 
disease. It is further stated in the official returns laid before Parlia- 
ment, that several months after the return of the army, there were 
on the sick list 217 officers, and 11,296 men! All this took place, 
notwithstanding the scientific employment of bark in every form. 

A curious and an interesting fact was communicated to me by Dr. 
Foot, (who served with the 17th regiment in India,) when he did me 
the honour to attend my lectures — that some Persian physicians 
apply ice to the surface of the body in the cold stage of intermittents, 
and, it is reported, with good effect. I have also heard that it is a 
practice with some in India, to use the cold affusion. 

It is proper, also, to mention the plan of preventing the paroxysm 
upon the first appearance of its approach, by applying tourniquets 
to the extremities, which was first noticed by Dr. Kellie, in the 1st 
and 2d volumes of the Annals of Medicine.* [After many experi- 
ments this gentleman came to the following conclusions: 1. If dur- 
ing the cold stage of an intermittent, the tourniquet be so applied as 
to obstruct the circulation in either the arms or legs, the hot stage 
will follow in the short period of three minutes. 2. The cold stage 
may be wholly prevented by applying the tourniquet before the 
paroxysm begins. 3. The result of thus preventing or abridging the 
cold stage, is to render the hot stage shorter and milder. Ten or 
fifteen minutes' pressure with the instrument is sufficient to produce 
the desired effect ; and it was found that a more protracted com- 
pression tended to defeat rather than promote the desired object.] 
The tourniquets appear to act, by confining the blood in the extremi- 
ties, and preventing so much at least of the congestion in internal 
organs. 

Treatment of the hot stage. — The best treatment which can be 
pursued in the hot stage, is to remove the bed-clothes as far as the 
season and the patient's feelings will admit ; to sponge the extremities 
with water ; to use cold drinks; and, in fact, to employ every means 
which can diminish the temperature of the body. If there be symp- 
toms of local inflammation, bleeding is to be had recourse to, either 

* This curious remedy is mentioned by Boisseau, p. 523, as if it were the original 
invention of Lallemand. 






INTERMITTENT FEVER. 95 

general or topical, which has always been employed by judicious 
practitioners in such circumstances. I need not speak of febrifuge 
and diaphoretic mixtures, which are very good for the druggist, will 
assist in filling the pockets of the routine practitioner, and suit the 
notions of a symptomatical physician. It is more than doubtful, 
whether such medicines ever diminished the violence, or shortened 
the duration, of the hot stage of an intermittent. 

Treatment in the sweating stage. — When the sweating stage 
commences, it must be encouraged until the uneasy feelings are 
relieved, or at least mitigated. Great injury is done by allowing 
patients to perspire longer, by which they are not only unnecessarily 
weakened, but the subsequent paroxysms of the disease are in general 
rendered more violent. The best way of arresting this stage, is to 
change the linen, after drying the patient carefully with towels and 
to place him on a couch. A second paroxysm has been frequently 
traced to a chill, occasioned by the coldness of the damp clothes, 
towards the termination of the sweating stage. Should there be no 
marks of any local inflammation, the patient may be offered light 
nourishing food, and even wine if necessary. 

Treatment during the interval. — The first thing to be done, is 
to determine whether or not there exists any local disease, and if so, 
what is its nature and seat. Medical men have hitherto deceived 
themselves very much by treating this disease, as well as many 
others, merely from its name ; because it is intermittent fever, bark 
must be prescribed ! Another error, into which they have fallen, is, 
that they imagine the only organic lesions which take place exist in 
the liver and spleen, whereas, the brain and the lungs suffer, perhaps, 
more frequently. I have seen fatal affections of the heart arise in 
the train of consequences from intermittent fever. Bronchitis is also 
of frequent occurrence. These facts are slated from my own expe- 
rience; and, except the last, respecting bronchitis, they are fully 
proved by the cases and dissections recorded by M. Bailly, as well 
m by the facts which are to be found in the works of Pringle, 
Cleghom, Chisholm, and others. 

If any organic disease exists, bark will be injurious, until it be 
either mitigated or entirely removed. Sir James Fellowes (Reports, 
page 350, slates, " that the dissections of those who died, discovered 
to us a series of morbid appearances of which we had no suspicion, 
and they enabled us to account for many of the phenomena of the 
complaint, and to form a more rational plan of treatment than that 
which we had at first adopted." M. Bailly came to the following 
practical conclusion ; that he bled, to dispose the system to receive the 
action of the bark, and that he has suddenly, by such means, subdued 
intermittent fevers, which had previously resisted all other means ; 
and he assures us at page 366, that although he would not altogether 
proscribe bark, yet he believes that bleeding alone, in most cases, 
above all, in our climate, would bring about a more substantial re- 
covery. He also makes a very strong statement at page 375. " In 
the commencement of an intermittent fever" says he, u one is 
almost always sure to destroy it by a large bleeding;" and he 
shows that this disease is not so fatal to poor debilitated subjects, as 



96 INTERMITTENT FEVER. 

to those who are better off, and better fed. For example, the mor- 
tality at Rome, where great misery prevails, is 1 in 26 of the whole 
population; whereas, in the marshes in the neighbourhood of the 
Sienne, the mortality is in the enormous proportion of 1 to 10 of the 
whole population. He also assures us, at page 383, that we are not 
to dread debility ; that those patients who were bled by himself 
abundantly, and at short intervals, not only were not depressed by 
this debility, but acquired in a few days a state of strength and 
health which they had not known for a long time. Had this distin- 
guished author been aware of the safety and success of the plan of 
bleeding in the cold stage, he would not have made the complaint, 
that in the worst intermittents, that is to say, those in which the 
patients died in the cold stage, he had "not time to employ bleed- 
ing." Speaking of the advantage of bleeding in this disease, he 
says at page 383 : — " Car fen except e toujours lesfevres intermit- 
tentes pernicieuses, dans lesquelles on n'aurait pas le temps ^em- 
ployer la saignie, si on ne se rendait pas maitre de mouvement 
nerveux par ce pricieux anti-periodique." 

It is in such instances that the great advantage of bleeding in the 
cold stage is most apparent. In some of M. Bailly's cases, stimu- 
lants and bark, in considerable quantities, were given without benefit, 
and in the majority the pulse is described as having been strong. 

Bark has been long in use, and although I never denied that it had 
virtues, yet, when given in substance, in the large doses which are 
admitted to be necessary, I have so frequently seen it do mischief, 
that the question has often suggested itself to me, whether it was not 
more injurious than beneficial? It seems to be injurious in many 
cases, by overloading the stomach and bowels with indigestible lig- 
neous fibre, and I have seen it cause serious intestinal irritation, as 
displayed by griping pains in the bowels, diarrhoea, and painful te- 
nesmus. On examining the stools in these cases, they seemed chiefly 
to consist of bark, with a considerable quantity of mucus, occasion- 
ally tinged with a little blood. That preparation of bark which is 
known by the name of the sulphate of quinine, is the greatest im- 
provement in modern pharmacy, and the knowledge of its beneficial 
effects in simple intermittents, affords sufficient proof of the virtues 
of the substances from which it is extracted ; yet this remedy, all- 
powerful as it is, is useless in the cold stage, and must also fail in 
cases complicated with organic disease. Dr. Fordyce, who had 
great experience in the treatment of this disease, states, that " in many 
cases of perfectly ?*egular tertians, the most skilful pructilioners 
have been baffled in the use of Peruvian bark, arid every other 
medicine recommended as useful in this disease" My youthful 
readers may rest assured, that the same observations are equally ap- 
plicable to the sulphate of quinine. They may rest satisfied that no 
means hitherto devised can be universally successful; and the cases 
have been already pointed out, in which the sulphate of quinine 
may be expected to be beneficial, as well as those in which the same 
happy result is not to be looked for. It cannot be loo strongly im- 
pressed upon the mind that experience has taught me to beware of 



INTERMITTENT FEVER. 97 

any preparation of bark while the patient has fever, complains of 
oppression at the praecordia, or has a loaded tongue. 

Sydenham's recommendation, of prescribing bark in the intervals, 
has been supported by subsequent experience. Bark is given in sub- 
stance, in decoction, infusion, and in extract; but no one who has 
seen the superior efficacy of the sulphate of quinine, will, I am per- 
suaded, if lie can obtain it, ever use bark in any of the other forms. 
With respect to the doses of quinine, Andral states that Lerminier has 
prescribed it in a very great number of cases, in two doses of three 
and four grains each, with an interval of half an hour, four or five 
hours before tbe paroxysm. And he assures us, that given in this 
manner, it has almost always cut the fever short. In some cases, the 
fever has been equally prevented, by the exhibition of the quinine 
twelve or fifteen hours before the paroxysm. Once the quinine was 
given by accident in the middle of the cold stage, and that paroxysm 
was neither weaker nor more intense than the preceding one. The 
greater part of those individuals who took the two doses of three grains 
each had slighter paroxysms than before; but the fever was not sud- 
denly cut short, as it was in those who tookthe twodoses of four grains 
each. He also states, that in two cases the sulphate of quinine did 
nut subdue the fever till the dose was increased to twelve grains; 
and Lerminier gave three individuals twenty grains each during the 
day, stopping the fever without producing any accident. But with 
several other patients, to all appearance in the same circumstances 
with the preceding, a few grains created troublesome nervous symp- 
toms, such as violent palpitation of the heart ; oppression; the glo- 
bus hystericus; general uneasiness; flying pains indifferent parts of 
the chest and abdomen.* 

The manner in which I have prescribed quinine is, to give three 

'! sof five grains each, with half an hour of interval immediately 

before the expected paroxysm; or three grains every half hour, 
beginning about three hours before the expected paroxysm. I have 
taken three and five grains, without feeling any thing unusual, and 
aAerwards ventured upon ten, hut a violent headache followed, which 
continued lor nearly three days; I have given ten grains, however, 
to others, on two or three occasions, without producing any such 
effect. 

. ; c has been long in use in intermittent fever, and there can 
be no doubt that it has often proved serviceable. Fowler's solution 
is the preparation now in general use, under the name of liquor 
aratnicalis; the dose is from two to twenty drops twice or thrice a 
day. Other tomes and bitters have been recommended; the best of 
these is the effusion of quassia. Opiates have been exhibited imme- 
diately before an expected paroxysm, sometimes with benefit, but 
they general y produced violent headache. Laxative medicines, to 
keep the bowels open, form an essential pan of the treatment ; and 
in general, the stools should be examined. I have met with cases 
which resisted every remedy, till it was ascertained that the patients 
had given erroneous accounts respecting the number and appearance 

Cliniouc Medicate, p. 488. 



98 [INTERMITTENT FEVER.] 

of the stools; and upon the bowels being put in proper order, the 
disease has given way without further trouble. From the idea that 
intermittent fever is a disease of debility, many practitioners give 
nourishing and stimulating diet, with wine, in all cases; but after 
the above pathological account, and the appearances found on dis- 
section, a word more need not be said to show the impropriety of such 
treatment. In some instances, nourishment and stimulants prove 
beneficial, where there is no local disease ; but in others, such treat- 
ment must prove prejudicial. The patient should be clothed accord- 
ing to the season of the year, and the temperature of the climate. He 
should avoid exposure in bad weather, (particularly in our climate 
during the prevalence of easterly winds,) and keep to the house after 
sunset, till he be sufficiently recovered. 

[With regard to the exhibition of quinine, some remarks remain to 
be presented. In this country it is seldom requisite to administer 
more than twenty grains during the first interval, and half that quan- 
tity during the following one, to effect a cure. Instances, however, 
frequently present themselves, in which the exhibition of a larger 
quantity than is necessary to attain this end, would be positively in- 
jurious; and practitioners have adopted the safer plan of giving a 
grain or two grains each hour, and limiting the quantity to the num- 
ber of grains above specified. It has been stated that this indispensa- 
ble remedy sometimes fails: it is, therefore, important to inquire into 
the causes of failure, and how they may be avoided. With regard 
to blisters, and all stimulants, in fevers, there is said to be a specific 
point in which they are to be employed : if they are applied before 
this has been attained, an increase of disease is the consequence. 
This point is a state of reduced local or sympathetic excitement in 
organs which, when stimuli are applied to them, will not cause re- 
action to be transmitted from one to another. Should the stomach 
be irritable, the quinine will most probably be rejected: but even 
should this not happen, it is liable to cause sympathetic irritations 
which may prove extremely embarrassing ; as, for example, increase 
of fever, determination of blood to the head, oppressive constriction 
of the chest, &c. It is, therefore, necessary first to obviate the general 
excitement ; and to prepare the stomach and bowels by the milder 
cathartics, and such other means as the occasion may demand, in 
order to obtain a perfect intermission before we administer the 
quinine. 

Cases, however, not unfrequently occur, in which the intermis- 
sion is complete, but owing to irritability of the stomach or repug- 
nance to medicines, the patient cannot take by the mouth a sufficient 
quantity of quinine to prevent the expected paroxysm. Under these 
circumstances we have two resources, — injection into the rectum 
and the endermic application of the medicine. For the purpose of 
injection, ten or fifteen grains of the sulphate of quinine should be 
dissolved in four ounces of mucilage of gum arabic or flax-seed, and 
administered at a single operation; and this must be repeated three 
or four times at intervals of three, six or eight hours, according to 
the duration of the intermission. 

The endermic plan is equally, but not so speedily available. A 



YELLOW FEVER. 99 

blister is to be applied to the epigastrium during the apyrexia, and 
the vesicle clipped at several points without removing the epidermis. 
To this vesicated surface apply six or eight grains of powdered 
quinine, (either alone or mixed with a little starch,) four times a day, 
for two successive days. I have seen this practice succeed most 
happily when the system had resisted all other modes of treatment ; 
and if the patient remains quiet, the irritation of the surface is not 
distressing, and can always be relieved by the application of a poul- 
tice without removing the quinine. 

There is a tendency in intermittents to return in about two weeks 
after the paroxysms have been stopped; and in order to break up 
this liability, I am in the practice of anticipating the paroxysm by 
recommencing the use of quinine two days before its expected recur- 
rence; and by pursuing this plan two or three times at equal inter- 
vals, the morbid habit may, in most instances, be speedily eradicated. 

Dr. Hurtle, of Port Spain, in the West Indies, has made extensive 
jiperine as a substitute for quinine in those cases in which the 
hitter has proved inefficacious. Seizing the first indications of the 
intermission, he gives three grains every hour until eighteen grains 
have been taken, and during the next following intermission, he 
Bepeats the same dose every three hours. Dr. Hartle speaks in the 
strongest terms of commendation of the piperine, which in certain 
cases he combines with blue-pill; and we may here remark, that the 
latter may often be administered with quinine to great advantage, 
especially in cases which present a persisting gastric irritation, as 
manifested by a furred tongue, nausea, &c. 

The hark of the common dog-wood (Cornus Florida,) is extensively 
used in some parts of the United States as a substitute for the pre- 
parations of bark. It is chiefly given in strong decoction.] 



MALIGNANT REMITTENT, OR YELLOW FEVER.* 

Tin- ii 1 fever in which there are remarkable remissions, followed 

1 hours by exacerbations; so thai it bears some resemblance 

to .in intermittent Tins circumstance has led Cullen to identify 

Ibeua : and in ins definition of intermittents, it will be observed that 

. remittents also ;— of the last he gives no separate 

definition. Remittent fever is a disease of warm climates, and when 

•1 is yellow it has obtained the name of yellow fever. The 

milder forma depend upon general functional derangement, which 

runs more quickly into disease of structure than is observed in the 

■ 1 this country. Remittent fever has a wide range of cha- 

luthor, in t.i- arrai ige 51, and again in this place, asea 

frnonymous. This nomenclature 1 b| 
opinion in 1 nil country, ibai I have prefixed Ine word malig* 
nmmi to the heading "i this chapter, hi ordei to prevent ambiguity, The mbsequeni 

>rv and treatment of various modi- 
. 



100 YELLOW FEVER. 

racter; modifications of the complaint occur without end, according 
to the organ or organs affected, the character of that affection, the 
constitution and habits of the patient, and the locality of his place of 
residence. In its severest form, the viscera of the three great cavi- 
ties are implicated from the first onset of the disease, and there is 
no complaint in which the appearances on dissection may be so truly 
predicted. 

Symptoms. — The disease begins sometimes with great excitement 
and without rigor; on other occasions, the rigor is severe. Generally 
speaking, there is some previous indisposition, such as headache and 
giddiness; want of appetite; symptoms of indigestion ; oppression at 
the praecordia; constipation of the bowels ; a feeling of debility and 
fainting, and bad nights. Sometimes it happens that the patient dies 
before reaction takes place, but this is comparatively rare ; sometimes 
cases occur where the seizure is sudden and unexpected — the patient 
is struck down, as it were; he loses his senses; irritability of the 
stomach soon appears; black vomiting ensues, and he is carried off 
in the course of thirty-six hours. " It often occured," says Dr. Fer- 
gusson, "to a well-seasoned soldier, mounting the night-guard in 
perfect health, to be seized with furious delirium while standing sen- 
try, and when carried to the barracks, to expire in all the horrors of 
the black vomit, within thirty hours from the first attack." This, it 
must be confessed, is the most severe form of the disease. 

There are many varieties, concerning each of which it is impossi- 
ble to treat in a work like the present. The most frequent form of 
the disease is that in which, after the rigor, which may be more or 
less severe, there quickly succeed violent reaction, heat of skin, and 
determination to the head, announced by the following well-marked 
symptoms: face flushed; conjunctiva injected, the eyes look heavy, 
and often feel burning; the expression of the countenance leads an 
experienced person to judge correctly of the severity of the attack. 
The respiration is hurried, and frequently laborious, often attended 
by cough, and the patient occasionally sighs, and seems to gasp for 
air. The head is thrown about from side to side ; and (he patient is 
excessively restless from anguish. Intolerance of light, and severe 
darting pains in the head, are sometimes complained of, as also in 
the small of the back and down the thighs. There is sometimes a 
burning pain in the pit of the stomach ; exquisite tenderness in the 
right hypochondrium; unquenchable thirst, with incessant retching 
of every thing taken into the stomach. The fluid ejected is mixed 
sometimes with much bile, and accompanied with a discharge of fla- 
tus, belched up with great violence; the urine suppressed. The pulse 
is various even in people similar in age, constitution, strength and 
habits; but in plethoric subjects who are seized soon after their ar- 
rival in warm climates, ihe pulse is quick, full, and bounding for a 
few hours, at least, after the reaction is fully developed. In some it 
is quick and not strong, and in others it is not particularly quick, and it 
is sometimes very irregular. The tongue is furred, perhaps red, but 
soon becomes parched and dark-coloured. These symptoms indicate 
the first stage of this fever. An anxious and distressed countenance, 
redness and sense of heat in the eyes, flushed face, intense headache, 



YELLOW FEVER. 101 

quick or laborious respiration, burning pain in the region of the 
stomach, with great thirst and excessive vomiting, announce a for- 
midable disease; but in my opinion, not so formidable and hopeless 
as another variety, in which there is some insensibility from the first 
with coma, weak and oppressed pulse, and cold extremities. 

The duration of the first stage is very uncertain. In severe cases 
it lasts from twelve to eighteen hours, but in those which are slighter, 
it may go on for three, four, or five days. 

In the second stage, the skin and eyes acquire a yellow tinge ; the 
heat subsides: the bead is confused, or delirium appears; the breath- 
ing becomes quicker and more anxious; the eyes begin to look 
glazed; the pulse sinks ; the retchings are rather more violent; the 
matter vomited becomes thicker and begins to look dark ; and if the 
person be sensible, he desponds; he occasionally falls asleep, but 
instantly awakes in great terror; sometimes he starts out of bed furi- 
ously delirious, but instantly falls down in a tremor upon the floor; 
the tongue is always parched, and in general covered with a dark 
fur; and the skin becomes clammy. In this stage, as well as in the 
first, there are often cramps in the belly and legs, which distress the 
patient much. The duration of this stage is also uncertain. 

The first stage sometimes terminates by a remission of the more 
urgent symptoms, when the patient and his friends indulge the fond 
hope that he may recover; indeed, these remissions often occur, but 
the deception is soon manifested by the recurrence of all the symptoms 
in an aggravated degree. In the second stage, there are remissions, 
also, particularly towards its termination, when the hope of recovery 
is again entertained ; for although the vomiting be more frequent and 
more copious, all uneasiness generally subsides, but the pulse sinks, 
becomes irregular, and intermits; although it sinks in strength, yet it 
increases in frequency. Nothing is retained in the stomach; the 
matter vomited is of a dark colour, resembling coffee grounds, and is 
termed the u black vomit." The breathing becomes more laborious; 
the tongue has perhaps lost its fur; it is shrunk, dry, and red; the 
BUnk and glazed : the whole features are sharpened. As 
death approaches, tin* limbs become cold as marble; there is a trou- 
blesome hiccup, winch, perhaps, has existed throughout the whole of 
»nd Btage. 1 [ssmori hage sometimes takes place from different 
parte of the body; the abdomen is frequently as tense as a drum ; 

and death Steals on slowly, or lakes place suddenly. 

Th<- symptoms in each of these stages must of course vary much 
Recording as the brain, the hums, and contents of the abdomen, are 
more or less affected. In some instances, the functions of the brain 
reman, undisturbed, even to the very conclusion of the last scene; 
at other '.lines, when then is extensive disease within the head, the 

delirium is more or less ferocious, or the patient is comatose : he ex- 
hibits a variety of nervous symptoms, such as convulsions, rigidity 
of the extremes, tremors, substiltcis tendinnm, and picking the bed- 

Otothes. Where the head is more BHghtly affected, the senses arc 

only occasionally ob cured; the patient may be said to be lethargic 

rather than C StO SJ bfl is easily roused, and, when roused, his 

countenance has a drunken or besotted appearance. 

9* 



102 YELLOW FEVER. 

If the lungs be affected, the breathing will be altered from that of 
health; mere dyspnoea may, however, exist, without any structural 
lesion of these organs. There may be cough also, attended or not 
with pain, followed by expectoration. I never saw a case of remit- 
tent fever in which the functions of the chylo-poietic viscera were 
not very seriously involved, as indicated by nausea and vomiting, 
thirst, pain in some region of the abdomen, meteorism, and altered 
condition of the stools. 

It has been mentioned that the functions of the kidneys seem to be 
almost, if not altogether suspended, little or no urine being passed 
during the course of the disease, and upon dissection the bladder is 
usually found much contracted, as in cholera. 

Another variety frequently met with in very sickly seasons, is that 
in which a person, after passing several restless nights, is able to go 
through some of his duties for the first two or three mornings; but 
this costs him a very great effort. His weakness increases, the 
bowels are out of order and constipated, or after having been for 
some time so, he may now complain of diarrhoea ; he feels alternate 
chills and heats, but the least exposure makes him complain of cold; 
his stomach now begins to get irritable, he takes to bed, the senses 
become rather obscured, the breathing is affected in no other way 
than being short, and he cannot, even when he makes an effort, dis- 
tend his lungs freely; he complains most of oppression at the prae- 
cordia. Sometimes a remission of most of these symptoms takes 
place, and his skin, which was never hot, and his pulse, which was 
never full, quick, and bounding, are now felt to be nearly natural; 
but in a few hours the symptoms become aggravated. The patient 
is more inclined to be comatose than restless, he complains now, per- 
haps, of violent pain in some region of the abdomen; the breathing 
is oppressed, the extremities cold and damp, while the surface of the 
abdomen and thorax is hotter than natural; hiccup comes on, the 
coldness steals onwards to the trunk, the pulse sinks, the countenance 
looks ghastly, and the patient's fate is quickly sealed. 

In a work like this, it is impossible to describe all the varieties of 
remittent fever which occur in warm countries. It will be sufficient 
to repeat, that sometimes the brain is the organ chiefly affected, 
when the symptoms are what may be called cerebral and nervous. 
In another set of cases, the disease is concentrated on the lungs, 
when the symptoms will vary accordingly. In another set, the dif- 
ferent organs within the abdomen may be affected, producing other 
varieties; and of these there may be various modifications and com- 
plications. 

Appearances on dissection. — These appearances vary much, ac- 
cording to the duration of the disease, and the organ which has been 
chiefly affected; some dying in the first stage, when we must not 
expect to see much, if any, appearance of inflammation. Some 
patients may have been largely depleted, and we shall therefore see 
less vascularity in their bodies than in those subjects who have lost 
no blood. Some individuals may have died of remittent fever, with 
organic lesions produced by previous diseases. All these circum- 



[YELLOW FEVER] J03 

stances must be kept in view when we are employed in the investi- 
gation of morbid appearances. 

Some blood is generally found in the heart and large vessels near 
it, and also in the Inngs, if the individual has not survived long, or 
been largely depleted. Plenrilic effusions are sometimes seen, and 
recent adhesions; the lungs themselves, in some instances, show vari- 
ous stages of inflammation, and the bronchial tubes are extensively 
diseased. In the abdomen as in the thorax, various lesions are 
occasionally observed, viz., the results of peritoneal inflammation, 
mortification of the bowels; the liver pulpy, soft, very yellow, and 
easily broken down ; sometimes its structure is completely destroyed, 
and it has been described by some authors to be in a state resembling 
"rotten cork." The spleen has been found altered in a similar 
manner. The stomach and bowels, when slit open, are found to 
contain more or less of the dark-coloured matter which lias been 
vomited during life, and the mucous membrane very vascular, of a 
deep red colour, not in depending portions only, but over a great 
extent of surface, sometimes throughout the whole. 

Until lately, it was not much the fashion to examine the mucous 
membranes minutely; and we still want information on the follow- 
ing points :— Whether the vessels which make such an appearance 
are in the mucous membrane or not? Whether the whole coats of 
the intestine are discoloured or not? Whether this colour is owing 
to inflammation or infiltration? At what particular points ulcera- 
tions are most frequently met with, together with a particular descrip- 
tion of the appearances of the ulcerated surfaces, and the adjacent 
mucous membrane? And it would confer a lasting favour upon me, 
and a benefit on science, if some enthusiastic pathologist would take 
the trouble to inject portions with Vermillion and size, and send 
them to this country, together with sketches showing the recent 
vascular appearances ; if to enrich my rapidly increasing museum, 
the greater obligation will be laid upon me, and no remuneration 
which it is in my power to bestow, will be thought too great a sacri- 
fice for such a boon.* 

I Tin: late lamented Dr. Lawrence has left the notes of fourteen 
i <>i" yellow fever, ex trained by him, in the city of New Orleans 
during the years 18 17-18-1 9 — which contain the following interest- 
ing facts In all except one, it was found that the stomach presented 
the appearances of active inflammation, particularly throughout the 
mucous surface of the target curvature. The case which formed an 
ption, exhibited the Btomach of "a dark dirty colour in some 
pans of ns internal surface. The small intestines were, in every 
. in a siaie of inflammation, particularly the duodenum, which, 
in several instances, was marked with dark livid spots. The stomach 
of one individual was " very large, and distended with air, contain- 
ing some black, coagulated stuff mixed with a mucous substance. 
i mucous substance was very copious, and much resembled the 

villous coat of the stomach. 1,, fad I had no doubt, but that some 
of it was the villous coal; as this < oat, particularly about the middle 

* '' : thai Doihing affords me greater pleasure than to spend aa 

hour in my museum wnh any pathological inquirer. 



104 [YELLOW FEVER.] 

of the stomach, was remarkably thin, and could be taken off with 
great ease. In some places were dark-looking patches, intimately 
united, resembling the coagulated substance in black vomit. I soon 
had scraped off the mucous coat from these places, and the dark 
matter was removed with it, as if it was the mucous coat itself, 
merely changed in colour. This would lead to the inference that the 
black vomit is nothing but a rejection of the disorganized villous coat 
of the stomach." The lungs and other viscera were generally found 
in a sound condition, with casual lesions, however, some of which 
were attributable to former disease, others to that which was of 
more recent origin; but there was no uniformity of occurrence. 

Dr. Jackson, in his history of the epidemic yellow fever which 
invaded Philadelphia in 1S20, has presented the result of the post 
mortem investigations which were then made. The following 
details are worthy of attention. "The brain did not exhibit marks 
of active inflammation. The veins of the dura and pia mater were 
mostly turgid with blood. Effusion of serum under the dura mater 
was found in three cases which had terminated with convulsions, 
and a larger proportion of it than ordinary appeared in the ventricles. 
The substance of the brain in no instance displayed any strong marks 
of disease. The viscera of the thorax presented no appearances that 
indicated their partaking largely of the diseased action of the system. 
It was among the abdominal viscera, that was to be discovered the 
evidence of the fatal storm, and of these the stomach was a uniform 
and principal sufferer. This viscus presented different appearances. 
I was much surprised to find it, on the first examination I made, 
without any marks of inflammation. The villous coat was of a 
rather whiter aspect than is usual, but a considerable quantity of 
black, coffee-like fluid was contained in the stomach. In eight or 
ten instances a nearly similar state of that organ was discovered, 
there being no inflammation, or a slight blush, mostly about the 
cardiac portion, being alone observable. The flowing out of the 
matter which constitutes black vomit, appears to have relieved the 
loaded vessels in those cases and to have terminated the inflamma- 
tion; but the death of the organ still ensued. It would seem, as I 
believe Dr. Physic has remarked in his dissections, that the formation 
of black vomit is an effort of nature to terminate violent inflammation 
of the stomach. But in the far greater number of instances, the 
stomach was highly inflamed. The inflammation was always con- 
fined to the villous coat, the muscular and peritoneal escaping the 
affection. It was not uniformly diffused over the surface, but would 
be deeper in one part than another. The cardiac portion was gene- 
rally more inflamed than the pyloric, and sometimes a greater 
intensity was observable between the superior and posterior sur- 
faces, a well-defined and distinct line separating them. No erosions 
or abrasions were discovered, though the villous coat was at times 
nearly livid, and broke with ease upon pressure with the nails. The 
vessels of the stomach were so turgid with blood, that portions of it 
cut out and dried, have formed very perfect preparations, exhibiting 
the ramifications of the vessels into their minutest divisions. The 
matter constituting black vomit was met with in every examination. 



[YELLOW FEVER] 105 

In two instances, in which it had been thrown up during life, with 
the usual characters, a fluid more resembling blood was found after 
death." The liver varied in appearance, never constantly presenting 
the same aspect: it was usually gorged with blood, but not always. 
The gall-bladder was sometimes distended with bile the colour and 
consistence of tar. In two instances, the internal coat and lining 
membrane of the ductus communis were inflamed. The spleen and 
pancreas generally natural. 

" The intestines most commonly were more or less inflamed, not in 
a uniform manner but in patches. They were in one subject con- 
tracted in some parts so much, that the little finger could scarcely be 
passed through them, and were swelled and distended in other parts. 
Three or four introsusceptions were formed in this case, but which 
were unattended with any inflammation at the spot where they ex- 
isted. This patient had taken large doses of calomel and had died 
strongly convulsed. The intestines always contained considerable 
quantities of black mucus, bearing a resemblance to the flocculi of 
black vomit. In some cases it was evidently sanguineous. The 
niinary Madder was sometimes much contracted and contained no 
Urine ; at other times small quantities were found in it. 

"The whole of the system of the vena portae was always distended 
with blood. It was at first supposed that the blood, being thus fluid, 
was in the dissolved state so often mentioned by writers. But Dr. 
Hewson, wishing to make some experiments, collected portions of 
it in cups. In the course of ten or fifteen minutes, it was firmly 
coagulated; and this was found in subsequent observations invariably 
to occur. The notion, therefore, of the blood being dissolved in tins 
ise, frequently described by writers as observed in their dissec- 
tions, is not correct. 

"The opinions that were held with respect to the nature of black 
vomit were various and loose, until the examinations instituted by 
Dr. Physic in 1798-99. It was demonstrated very satisfactorily, that 

it pro* led solely from the stomach, that it did not partake iu the. 

of the nature of bile, which had been the commonly 
ived doctrine; and in fad thai the liver had no share in its pro- 
duction. Dr. Physic considers Mads- vomit to be a diseased secretion 
from the vessels of the stomach. Tins opinion is entitled to great 
attention, and is rendered eery probable by the arguments and experi- 
ments wiili winch it is supported. Hut from the great turgescence 
of the whole portal system always found distended with blood, I am 
disposed to believe thai the inflammation of the stomach and of the 
other abdominal viscera in this disease is venous, and nol arterial, 
and arises from an engorgement of the veins extending to their 
minutest division and first origin, should tins view be correct, black 
vomit, it is not unlikely, may ai ise from a sanguineous effusion from 
the capillary extremities of the veins. The matter of black vomit 
nol m untain invariably the same characters, but recedes more 
or less from, or approaches to, an appearance of blood. I have seen 
i which the discharge towards tin; termination became 
and a similar fluid was also found in the iutes- 



106 YELLOW FEVER. 

"Dr. Rhees, the resident physician at the city hospital, instituted 
a series of observations on the black vomit, with a solar microscope. 
Innumerable quantities of animalculae were found to exist in it. A 
single drop contained many thousands, apparently a congeries of them. 
The black mucus of the intestines exhibited the same phenomena. 
When the fresh matter thrown from the stomach was examined, the 
animalculae were alive, and in constant motion, but if taken from the 
dead subject, or inspected after standing some time, they were always 
dead and quiescent. Comparative examinations were made of the 
discharges from the stomachs of patients ill with autumnal, bilious, 
and remittent fevers, but no similar appearances were discovered."] 

Causes. — It has already been shown that the extremes of cold 
and heat are not very productive sources of disease. Fevers are pro- 
duced more by sudden changes of temperature, or by heat conjoined 
with moisture, than by heat itself, however intense. The state of 
the mind has also great influence, as well as the habits of the indi- 
vidual. 

It has often been remarked, that there is great mortality among 
troops after their first arrival in a tropical climate. This is some- 
times to be attributed to a want of due care on the part of the govern- 
ment, in choosing the season at which they ought to arrive at their 
destination. I believe a greater number of men will be lost during 
the first twelve months, if they are landed at the beginning of the 
rainy season, than after its termination ; perhaps the loss will be dou- 
ble. Great care should be taken in the selection of the troops; none 
but well-seasoned soldiers should be sent out. Sir George Ballingall 
has written very strongly and sensibly upon this subject, in his ex- 
cellent work on some of the diseases incident to the troops in India. 
No young recruit should be sent out to be made a soldier ; all his 
drills and exercises should be completed in this country. 

When troops arrive in a distant country after a tedious voyage, it 
is natural to expect that they will indulge themselves in many ways 
beyond due bounds. Cheap new rum, and an abundant supply of 
delicious fruits, attract their attention, and do incalculable mischief. 
Some men leave England in the utmost state of despondency, and 
it will, in general, be observed that they are the first victims. New 
comers are also apt to indulge in drinking too largely of cold fluids, 
and sitting in a thorough draft of air when the body is over-heated ; 
in fact, it requires considerable time before a European obtains know- 
ledge to manage himself properly. Some are fool-hardy, and take 
no care of themselves whatever; and I feel convinced, that an 
amusement in which young strangers too frequently indulge, known 
in the West Indies by the name of "Dignity Balls," causes many 
a death. 

Many cases have come under my observation, in which fatal 
attacks of fever appeared to have been produced by inattention to 
the bowels; and I am convinced that it is a matter of the first im- 
portance to every one going to a warm climate, to keep his bowels 
open by gentle medicine. Repeated observation has induced me to 
believe that a person may very often be exposed to any or all the 
causes of fever, even in the most unhealthy situations, without being 



YELLOW FEVER. \qj 

affected, provided his bowels be in a proper state, his mind free from 
apprehension, and his habits good. 

These are a few of the many causes of disease in warm countries, 
entirely independent of the influence of contagion, marsh miasm, and 
epidemic influence. 

Pathology. — With respect to this part of the subject, I have little 
to say, except to refer to the general account already given of the 
pathology of fever. Remittent fevers have the same pathology as 
other fevers, only it will be found in general that the structure of 
more organs is involved than in the ordinary fevers of this country. 
But it may be stated, that no species of fever upholds the doctrines 
of Broussais more completely than the remittent. 

Treat ment. — There have been as great revolutions in the treat- 
ment of the fevers of warm climates, as in that of any other class of 
diseases. The supporters of the doctrines of putridity have, of 
course, always avoided bleeding even in the first stage, when they 
admit the existence of inflammation, for fear of the debility which 
they expect in the latter stages. They begin by clearing out the 
puma- vise, and then have recourse to bark in very large doses with- 
out regard to the state of the stomach, local inflammations, or any 
other circumstances. This is the practice recommended by Clark, 
Liml. and others. They prescribe opium for the purpose of keep- 
ins the bark upon the stomach, and give wine and brandy in con- 
e quantities, with the view of supporting the strength, keeping 
off the stage of collapse, and preventing putridity. But it may be 
stand without fear of contradiction, that this practice cannot be too 
te% erely condemned. It should be recollected, that the stage of col- 
lapee must come on sooner or later. No person can pass from a state 
of fever into that of health and strength; and the longer it is post- 
poned the worse will it be for the patient, whose situation very much 
resembles that of an individual in debt, who puts off the evil day 
from tune to time by various means, and when his creditors meet at 
is found without means to pay, whereas, had he disclosed his 
real situ mm >q Qgth of his credit would have survived 

the shock without injury. 

Dr. Chisholm, about the year 17!»3, introduced the plan 
of affecting the system with mercury as speedily as possible, employ- 

• dil g in small quantity, and only occasionally, more with a 

view of enabling the system to receive the mercury, than as a pow- 
erful measure calculated to subdue the diseased action. Now my 
recommendation would be the reverse, to use bleeding early as the 
. m cases which require depletion, and mercury after- 

ifl an auxiliary. The celebrated Dr. Rush bled and gave 

calomel to diminish the increased action j and the reason this practice 

did not maintain its ground is, thai he trusted a little to the bleeding, 
and a in lie to the calomel, on the principle, of gradually depleting the 

•yttem. II" rarely took more than ten ounces of Mood at a tune; 

and notwithstanding he repeated the bleedings from day to day, yet 

• r produced sufficiently decided effects upon the disease, 
although he sometimes took away from one hundred to one hundred 

and filty ounces; of bloud. The practice would have been far more 



108 YELLOW FEVER. 

successful, had he taken away twenty, thirty, or forty ounces at 
once. 

When bleeding is thought necessary in this disease, it is trifling 
with the patient's life if the blood be not allowed to flow till some 
impression is made upon the disease, and upon the system ; and it is 
impossible to determine beforehand the quantity which will produce 
one or other of these effects. This is the kind of practice which 
was pursued by myself and many others who were in the West 
Indies nearly thirty years ago; and it appeared to be attended with 
great success. 

Some practitioners trust almost exclusively to the action of mer- 
cury, and in India more particularly, it is deeply to be regretted that 
a great waste of human life has consequently taken place. Some 
years ago, Dr. Haliday, of the Honourable East India Company 
service, was, by order of the Marquis of Hastings, put under arrest, 
and deprived of rank and pay, for showing, by most incontrovertible 
evidence, that in the general hospital of Calcutta, the enormous 
quantity of 26 pounds of calomel were consumed by 8S6 patients: 
And that under the painful digestion of this mineral, the proportion 
of deaths was 1 in about 6| of the whole sick list — whilst under a 
more rational treatment the mortality was reduced about one-half: 
In fact, that the mortality bore almost an exact ratio with the quan- 
tity of calomel exhibited. After a delay of many years, Dr. Haliday 
was restored to his rank by the express order, more than once repeated, 
of the India directors. This transaction has never been brought 
before the British public, but having carefully perused all the evi- 
dence, I have no hesitation in declaring that as a piece of persecu- 
tion, from beginning to end, there is no parallel case to be found in 
the annals of any free country. Wherever the story is known, it 
must cause a blot, never to be effaced, upon the memory of the then 
Governor-General of India and all his advisers, military as well as 
medical.* The result of the practice of the rising medical officers in 
India has fully corroborated the statements formerly made by Dr. 
Haliday; and mercury is now not so much abused as it once was. 
And as pathological knowledge advances in India, which it is doing 
rapidly, mercury will be still less trusted to. It must be always kept 
in remembrance, however, that the liver suffers more frequently in 
the fevers of warm climates than in this country, and therefore mer- 
cury, under judicious management, cannot be altogether dispensed 
with. 

In 1796, the deaths in the West Indies under Dr. Chisholm's mer- 
curial plan were never exceeded, amounting to nearly one-half of the 
whole number of troops. 

* The author regrets want of sufficient space to speak more fully of the transaction, 
but he cannot avoid annexing an extract from a letter addressed by the East India 
Directors to the governor-general, afier full investigation. "In the mean time we 
authorize and direct you to remove the restrictions you have placed to the further 
employment of Dr. Haliday, unless stronger objections shall exist to his restoration, 
than those which have been reported to us in the proceedings under consideration. 
It appears to us, that your interference in the professional discussions which were 
brought under your notice, has been carried further than is desirable, or consistent 
with the improvement of medical science." Notwithstanding this communication, 
Dr. Haliday was doomed to undergo still further persecutions. 



YELLOW FEVER. 109 

The bold and decisive use of the lancet in this disease has met 
with an able and influential advocate in Dr. Jackson, who was in- 
spector of army hospitals in St. Domingo, and subsequently in the 
Windward Islands. This distinguished individual bled to the extent 
of thirty, forty, fifty, sixty, and even eighty ounces at once in the 
very beginning; and he repeated the operation within three hours, 
if the first evacuation had not been productive of permanent benefit; 
after this he gave calomel in doses of from five to thirty grains, re- 
peated every third or fourth hour. 

Bleeding has been strongly objected to, on account of the condi- 
tion of the blood. In some cases it appears of a very dark colour, 
and streaked with red and bluish lines; it coagulates very imper- 
fectly, sometimes not at all, and does not separate any serum. It 
is in the state commonly called "dissolved blood," and which 
announces, it is supposed, a putrid state of the whole body, and 
particularly of the fluids. This appearance does not deter me from 
recommending a repetition of the operation, as I have long been 
aware thai it exists more or less in all severe cases of congestion. It 
has been fn qnently seen by my pupils, in cases of intermittent fever, 
in which I bind in the cold stage; and also in cases of congestive 
fever. It has also been noticed in Asiatic cholera, and a similar 
condition of blood may be seen in patients affected with the common 
cholera of this country, and has been observed in some severe cases 
of bronchitis. 

Dr. Rush says he paid no attention to the dissolved state of the 
blood, when it appeared on the first or second day of the disorder; 
but repeated the bleeding afterwards in every case where the pulse 
indicated it. He states a fact which I can verify, that it is common 
si/.y blood succeed to that which was dissolved. He states 
also, id it [»e was never deterred by the presence of petechia? from 
Uletting, in cases in which the pulse retained its fulness or ten- 
sion. 

Although the necessity of keeping the bowels freely open in this 
innsi be admitted, yet I had not been long in a warm 

climate before I observed the injurious consequences produced by 
Strong drastic purgatives, and many individuals were lost by the 
eniiMaut irritation kept up by this means. The appearances on dis- 

!i, too, warrant me in cautioning practitioners not to persevere 

mil' m using Strong purgatives; there can be no advantage from 

moderating irritation ami increased action, if these be immediately 

ictted. The eommon purgative formerly used in the West Indies, 

len grains of calomel and a scruple of jalap. Emetics have been 
often extolled, but I believe every experienced tropical physician will 
agree with me in esutioning young practitioners against their indis- 

oriminate employ n\ \ irritability of ihe stomach is one of the most 

frequent and troublesome symptoms, and once, excited, it is always 
difficult, in many cases impossible, to restrain it. I have seen emetics 
exhibited, and the vomiting has continued till death, in spite of every 
remedy, The a ime c intion is necessary with regard to those reme- 
dies that ar.- employed tor moderating the action of the heart and 

as, When in the West Indies, I have often regretted not having 

ID 



HO [YELLOW FEVER.] 

a command of leeches, and am persuaded, that upon a proper repre- 
sentation, the government would take steps, at whatever expense, to 
secure a proper supply to the medical officers of the army and navy. 
There is no disease in which dissection reveals so many organic 
lesions, and the efficacy of abstracting blood in such cases by leeches 
is generally admitted, particularly after the severity of the disease has 
been broken by the lancet. 

After the publication of Dr. Currie's work, cold affusion became 
generally used in remittent fevers, but much mischief followed, and 
it has fallen into disuse. Dr. Currie has distinctly stated, that it is not 
admissible in cases where there is any internal inflammation ; there- 
fore, in the majority of cases of the fever now under consideration, 
the practice will be found to be injurious rather than beneficial. But 
when the skin is dry and burning, nothing gives the patient more 
temporary relief than sponging the body with water, or vinegar and 
water, which ought to be very frequently repeated. 

The application of blisters and other contra-irritants is highly 
serviceable after bleeding, &c, but should never be had recourse to 
in this, or any other fever, in the early stage of the disease. 

Stimulants sometimes appear to save life, but in candour it must 
be mentioned .that I have also seen them very prejudicial; nothing 
in the whole practice of physic requires more caution and experience 
than their exhibition; but I shall speak more fully upon this subject 
when treating of the fevers which prevail in this country. The best 
stimulants are wine and brandy ; in many cases where the stomach is 
irritable, brandy will be found to be superior to wine. In the last stage, 
great care should be taken to support the heat of the extremities. 

Partly from the notion of the resemblance between remittent and 
intermittent fevers, and partly from this disease being supposed to be 
one of putridity, bark has been employed. By some it is recom- 
mended throughout the whole course of the disease, by others only 
during the remissions, and in the last stage; but I believe it has done 
more mischief than good. I have often had to blame myself for 
bringing on an exacerbation, not only by the use of bark, but by 
nourishment and stimulants, during the first remissions ; and a strong 
impression is left upon my mind, that it would be better for patients 
if less were done for them in the state of apyrexia, and also in the 
commencement of convalescence. No doubt, however, can be en- 
tertained, that the sulphate of quinine will be of signal service in 
many cases. 

[The method of treating yellow fever by large doses of calomel has 
for years been pursued throughout the United States, particularly in 
the south. The efficacy of this practice has latterly been questioned, 
and physicians have in a great measure yielded to the change in 
public sentiment. It is at least evident, that the exhibition of the 
enormous quantities of mercury which have been given both in this 
disease, and in other forms of fever, is not attended with the unfail- 
ing success which alone could warrant its employment; and the con- 
sequences have been so frequently destructive to health and comfort, 
as to lead to the opposite extreme of total proscription of this powerful 
article : a circumstance much to be regretted, as in proper doses, and 



[YELLOW EEVER.] HI 

at suitable periods of the disease, its use is highly serviceable. If the 
general system is affected with considerable reaction, venesection is 
required; but in most cases the prompt application of leeches, or 
cups, as near as possible to the diseased organs, is followed by a 
decided amelioration of the symptoms. They should not be placed, 
however, so immediately in contact as to run the risk of increasing 
excitement. As an auxiliary measure, the sedative impression of 
cold has a beneficial effect, and is peculiarly grateful to the patient: 
iced drinks, ice applied to the head, if this organ presents symptoms 
of disordered action, and the injection of cooling enemata into the 
bowels, are the modes of application. The use of small doses of 
calomel, or blue pill, will admirably promote the cure when the force 
of the local irritation has been reduced; and it only remains to un- 
lock the secretions, and gradually restore them to a natural state. To 
sum up the most approved plan of treatment in concise terms, we 
are to remove all irritating causes; mild, soothing, diluent substances 
are to be administered; while local and general symptoms are to be 
relieved by the means already indicated. The allowance of such 
diet as is suited to the condition of the digestive powers, will be regu- 
lated by the principles which guide us in inflammatory conditions of 
the stomach.* 

Yellow fever has, of late years, been treated on a new plan in the 
United States, viz., by giving quinine in very large doses at a par- 
ticular stage of the disease. Thus, from twenty to sixty or eighty 
grains are administered at the commencement of the fever, while 
the. morbid action appears to be in process of formation, that is to 
within six or eight hours after the accession of the malady. 
When taken under such circumstances, the first effects are a very 
slight increase of the febrile symptoms; the pulse, perhaps, becomes 
quickened, the respiration more hurried, and the usual consequences 
of stimuli .ire present. This condition, however, is but transient, and 
ifl promptly followed by corresponding depression. All the more 
violent symptoms subside ; the temperature of the surface is lowered; 
pain diminished; the pulse is gentle ami subdued; the skin is co- 
I with a healthy moisture ; in short, the chain of morbid associa- 
tions becomes broken, sleep is superinduced, from which the patient 
awakes refreshed and subsequently better, and from twenty-tour to 
thirty-six I rs i^ considered in a state of convalescence. The treat- 
ment is, of course, nol exclusively confined to the employment of 
quinine, though this is the chief remedial agent The usual means 
oi obviating tendencies to local irritation must be resorted to. The 
skilful practitioner will modify his curative measures according to 
the necessities oi the ease; cupping, leeching, the warm bath, and 
local applications, may be used as circumstances call lor their em- 
ployment. The quinine is administered in a single dose; the object 
being to bring aboul the sedative influence of the remedy before any 
of the organs, as the head, stomach, &c, become specially affected 
by thi If it should fail to produce the anticipated effect, 

•r -• ftbe advantage of this plan, we refer to the cases of Drs. Barton 

and 1 1 iriag ihe year 1 >:;::, and reported in the Ameri- 



112 INFANTILE REMITTENT FEVER. 

the case is too far advanced for a second trial, and it must be treated 
on genera! pathological principles. Let it be remembered, however, 
that in thirty or forty cases which have been subjected to this novel 
curative method, not one has terminated fatally. The action of the 
quinine has been uniformly most salutary, operating like a charm, 
and dissipating the symptoms of the malady ere they become con- 
centrated on different organs."* 

On this point we have no experience of our own ; but as it comes 
from medical men of acknowledged ability and extensive practice 
in yellow fever in New Orleans, and other southern cities, wo gladly 
insert the facts as announced by them ; at the same time, we believe 
it has been proved that this course of treatment has not effected the 
same happy results in subsequent years, but on the contrary, has often 
been attended with entire disappointment ; a fact which is amply 
accounted for in the known variableness of yellow fever in differ- 
ent seasons even in the same localities.] 



INFANTILE REMITTENT. 

Many diseases occurring in infancy and childhood have obtained 
this name, viz., inflammation of the brain and bines, the irritative 
fever produced by teething and worms, rheumatic affections. &c; in 
all of which, and even in cerebral and pulmonary inflammations, 
there are very remarkable remissions in young subjects. But the 
disease which is to be considered in this section is a febrile affection 
which is, in general, found to depend on irritation, inflammation, or 
ulceration of the mucous membrane of the stomach and bowels. 

Symptoms. — The little subject is observed to be listless, fretful, 
and thirsty, and to pass restless nights, with some heat of skin. In 
a few days the skin is hot and dry, the thirst and restlessness are 
increased, the breathing is hurried, and the pulse very quick. The 
child is more uneasy and restless at night, but towards morning the 
skin becomes slightly moist, when it has some disturbed sleep; the 
bowels ar« constipated, or there is diarrhoea, but the former is more 
frequently met with; or there is frequent desire to go to stool, but 
little is passed; if there be any evacuation, it is discoloured and 
fetid. In colour, the evacuations are not always dark, but some- 
times white, showing a deficiency of bile, and sometimes bluish, but 
always offensive, often mixed with mucus, and occasionally with 
a little blood. The child cries frequently, and draws its knees up to 
the breast— it cries more when the belly is touched, which is hotter 
than the rest of the body, and tympanitic. It prefers to drink cold 
water, and frequently shows signs of increased abdominal pain after 
a copious draught; the stomach is occasionally very irritable, and 
every thing is vomited ; the tongue, being at first moist and loaded, 

Medical Examiner, 1840. 



INFANTILE REMITTENT FEVER. 113 

and occasionally very red round the edges, soon becomes dry over a 
triangular space at the tip. On some occasions it is difficult to keep 
the hands and feet sufficiently warm, while the face is flushed and 
the rest of the body parched. 

If proper treatment he not soon pursued, the functions of the brain 
occasionally become disturbed, and it is difficult, in many cases 
impossible; to determine whether or not disease of structure is going 
on in the head. 

On other occasions the respiration, which has been hurried from 
the first, owing, perhaps, merely to increased circulation through the 
lungs, becomes laborious, a troublesome short cough also appears, 
and. in general, auscultation will announce a more or less extensive 
inflammation of the bronchial membrane; and if the disease be not 
Subdued, wheezing and expectoration follow. Sometimes the child 
appears to be recovering for a few weeks, and then relapses; during 
the remissions he gains flesh and strength, but the abdomen remains 
tumid, and in this condition he may continue getting better and 
worse till the mesenteric glands become enlarged, or dropsical effu- 
sion takes place in the abdomen ; the emaciation increases ; there is 
no fever except at night ; the appetite is occasionally voracious. In 
fact, the little sufferer presents all the symptoms of the disease usually 
known by the name of tabes mesenterica. 

Appearances on dissection. — The chief traces of disease are found 
in the abdomen. Sometimes peritoneal inflammation seems to have 
been the immediate cause of death, and I have had many opportuni- 
ties of ascertaining that inflammation of this tissue has been excited 
by the extension of ulceration from the mucous membrane, through 
the muscular and serous tissues. The mesenteric glands are found 
very generally enlarged, sometimes enormously so, and seem to con- 
sist of a cheesy-looking matter, which is usually described as de- 
pending on scrofulous anion, but perhaps hastily, and without good 
foundation. <>m cutting into the stomach and bowels, the mucous 
membrane will be found in various conditions, occasionally very 
ular, thickened, softened, or ulcerated. The ulcerations in the 
ilium and colon Strictly resemble those which I have afterwards to 
describe in the bowel complaints of children, except that the whole 
mucous surface ol ihe colon is occasionally involved in one sheet of 
ration, with a rough and ragged surface and hypertrophy of the 
other coats, as is observed in many cases of phthisis pulmonalis. 
Whim there is no ulceration, we sometimes see mere vascularity, 
wiih or withoul softening of the mucous membrane ; the quantity of 
thick mucus adhering firmly to the surface is very great; and it is 
»us, that after being carefully removed by washing and wiping, 
I have seen fresh exud itions take place during maceration, not only 
in water, but in spirits; and I have been surprised, after having laid 

cis lor many months, to find Ihem again thickly 

•d over with i niic i is. Large abrasions are also sometimes (bond 
m the mucous membraneoi the stomaeh, at the splenic extremity, 

which have penetrated through all the issues at i point ; in other 

. appeared to he converted into a gelatinous mass. From 
careful i \ tmination, it would seem that tins kind of disorganization 

10* 



114 INFANTILE REMITTENT FEVER. 

is the effect of previous inflammation. This appearance has excited 
considerable interest of late years, and has been noticed on the conti- 
nent by Cruveilhier and others, and in this country, many years ago, 
by Underwood. The profession stands greatly indebted to Dr. John 
Gairdner of Edinburgh, who has collected a great number of interest- 
ing cases, some of which occurred in his own practice, and which 
will be found in the first and second volumes of the Medico-Chirur- 
gical Transactions of Edinburgh. 

It has been stated in the description of the complaint, that symp- 
toms of cerebral and pulmonary disease sometimes become lighted 
up ; but on watching the progress of the affection, these are observed 
not to form essential parts of it ; nevertheless, the appearances some- 
times found in tiie head and thorax, deserve to be mentioned. 

In the head there is generally effusion in the ventricles, and also 
between the arachnoid and pia mater, with great vascularity in the 
latter membrane. 

In the thorax, the most common morbid appearance is found in 
the bronchial membrane, which is vascular, and the tubes are more 
or less filled with mucus; which is to be described more particularly 
when treating of bronchitis. The substance of the lungs also shows 
various degrees of inflammation, and occasionally there are traces of 
pleuritis. 

Causes. — These are indigestible food, such as crude vegetables, 
sweet-meats, &c; the habit of allowing children to eat too many 
articles of food at one meal; together with insufficient clothing and 
unwholesome food, to which the children of the poor are so fre- 
quently exposed. Teething sometimes produces symptoms like those 
above described. 

Pathological remarks. From this view of the phenomena of 
the disease, together with the appearances on dissection, and the 
causes, the reader will have anticipated what I have to state respect- 
ing the nature and seat of the disease, that it depends on irritation 
and inflammation of the mucous membrane of the stomach and 
bowels, particularly of the latter. 

Treatment. — Abstinence from solid food is necessary; even bis- 
cuits, crusts of bread, and the pulp of oranges, frequently produce 
relapses. Leeches should be applied to the abdomen in all cases 
where there is much vascular action, pain, or heat of skin, if gentle 
laxatives, frequently repeated, do not mitigate the symptoms. Fo- 
mentations should be applied to the abdomen ; when the skin is hot 
and parched, sponging the body frequently with tepid water will 
often take off the restlessness. The practitioner should be particular 
in all cases, but more especially in attending children, to examine 
the stools, and the quantity of clothes with which they are too often 
covered. A remarkable case occurred to me four or five years ago, 
which is worthy of being mentioned. A child aged seven was seized 
with some degree of chilliness, followed by reaction, thirst, want of 
appetite, nausea; the respiration became hurried, and he complained 
of considerable headache. He was ill for five or six days before I 
saw him, and had taken repeated doses of salts and senna. On 
examination, I found the abdomen distended, tense, tympanitic, and 



INFANTILE REMITTENT FEVER. 115 

somewhat painful to the touch ; his thirst was considerable, the re- 
spiration quick, the face flushed, with some headache, and he com- 
plained of noise and light ; the tongue loaded with a white fur, moist 
everywhere but a small triangular space at the tip, which was red, 
as were also the edges; he had no vomiting, but a dislike even to 
the smell of solid food; he was very uneasy and restless, passed 
sleepless nights, and the pulse was quick, but not particularly strong. 
During the course of eight days, leeches and fomentations were fre- 
quently had recourse to and with marked relief, but always of short 
duration. Gentle laxatives were frequently given, and injections 
administered, but all to no purpose ; the stools were slimy and scanty, 
and as the child had been so long without even taking gruel, it was 
imagined that the bowels were empty. The abdomen was blistered. 
At last, something excited my suspicion respecting the state of the 
bowels, and castor oil was given on the fourteenth day, every second 
or third hour, after a moderate dose of calomel and jalap. On going 
to stool, he complained very much of pain ; he was observed to 
strain most violently; and after some time, he passed what appeared 
to be a very large fetid stool, which surprised me very much; 
it was so large that I was induced to examine it minutely, when 
three hard masses were discovered, surrounded with a great quantity 
of mucus. Upon close examination, they proved to be a dollar bis- 
cuit, and two pieces of solid meat; the biscuit was soft, but quite 
undigested and whole, with the exception of its margin, part of which 
had been broken oil"; the depressions generally made on the surface 
of biscuits were quite distinct, as also several of the letters of the 
baker's name. This biscuit was seen by a great number of gentle- 
man who were attending my lectures at the time, and is now in my 
museum. One piece of meat was large, and must have formed a 
good mouthful ; the other was small, but both were quite unchanged 
by digestion, and not so putrid as might have been expected. It 
appeared that the boy was frequently in the habit of bolting what- 
evei he hid in Ins mouth, without mastication. His recovery was 
progressive aAer he i">t rid of these substances. 

[f the disease become chronic, occasional leeching, perseverance 
in _''■!;• . a nourishing, but mild and bland diet, a long per- 

m vera nee in contra-irritation on the surface of the abdomen, hy 
of the tartar-emetic ointment, and an occasional warm hath, 
an: the best remedies. If there are evidences of effusion into the ab- 
domen, with a scanty secretion of urine, a preparation of calomel, 
squills, and digitalis, in doses proportioned to the age and strength of 
Im patient, will ho found serviceable, together with drinks acidulated 

wiih cream of tartar. Many of the students attending my Dispensary, 

ii remarkable recoveries under the plan of ireatmeut above 
described, even in cases which at first appeared lo he almost hope- 
less. 



116 CONTINUED FEVER. 



REMITTENT AND CONTINUED FEVER. 

Cullen and others maintain, "that there is no such disease as that 
which the schools have called a Continued Fever." There can he 
no doubt, however, that there is such a class of diseases, if we look 
at nature ; and that Cullen would have seen it if he could have looked 
through any other medium than that of his own erroneous theories. 
Cullen's definition — "Fevers, ivithout intermission, and without 
being produced by marsh miasmata, but with remissions and 
exacerbations, though not always considerable, continuing; two 
paroxysms in each day. 

Often have I seen slight continued fevers terminate in regular in- 
termittent, and intermittent in continued fever, at least as much as 
any fever can be said to be continued ; continued until death closed 
the scene, or rather I should have said, till that stage of collapse took 
place which precedes death. This definition must be admitted to be 
too finely spun; for if there be no continued fever, it may be also said 
there is no continued inflammation of the brain, or of any other 
organ. In all fevers, as in all diseases, there are intervals in which 
the patient is easier, and appears, perhaps, rather better; and there 
are also nocturnal exacerbations, which may be partly attributed to 
the sick being worn out and made worse by fatigue, heat, light, and 
noise during the previous day. 

All the fevers which are to be described in this class, are called 
"idiopathic," as well by those writers who have identified in their 
own minds fever with inflammation, but who will not allow the 
existence of "any primary local disease" unless that disease be 
one of inflammation, as by others, who deny the existence of local 
inflammation in fever. Cullen belonged to this last class, and he 
states that he never had seen a case of inflammatory fever but one; 
therefore he endeavoured to place these fevers altogether beyond 
the pale of pathology. In this spirit has he framed the definition of 
fevers : u *flfter languor, lassitude, and other signs of debility, py- 
rexia ; ivithout any primary local disease." The reader will see 
at once the absurdity of this symptomatica! pathology, which denies 
to any fever whatever, except hectic, any primary local disease: for 
Cullen is subsequently compelled to place inflammatory fever as one 
of his orders; and although he gives a very common-place reason 
for calling inflammatory fever "synocha," and an explanation that 
this term is not to be used in its " vulgar acceptation;" yet we are 
not to be told in the present day, that the pathology of a disease can 
be changed by a mere name, which any one may invent. All Cul- 
len's disciples will be found to fall into the same error, but they be- 
come caught in their own net in describing the order synochus, 
which, according to them, is a compound fever, of an inflammatory 
nature in the first stage, and typhoid in the second. 

Cullen, in the 141st paragraph, makes the following statement : 

"In the case of synocha, {inflammatory fever,) therefore, there 
is little doubt about the propriety of blood-letting; but there are 
other species of fever, as the synochus, in which a violent reaction 



FEVER FROM FUNCTIONAL DERANGEMENT. 117 

and phlogistic diathesis appear, and prevail during some part of the 
course of the disease; while, at the same time, these circumstances 
do not constitute the principal part of the disease, nor are to be 
expected to continue during the whole course of it; and it is well 
known that, in many cases, the stale of violent reaction is to be 
succeeded, sooner or later, by a state of debility, from the excess of 
which the danger of the disease is chiefly to arise. It is therefore 
necessary that, in many cases, blood-letting should be avoided; and 
even although, daring the inflammatory state of the disease, it 
may be proper, it will be necessary to take care that the evacuation 
be not so large as to increase the state of debility which is to follow. 

It was Dr. Baillie's opinion, that typhus was as rare as Cullen 
states inflammatory fever to be. The truth is, that much depends 
upon the class of people among whom a physician practises, and the 
period of the disease at which he generally sees his patients. Our 
army and navy surgeons have to treat fevers in subjects well fed 
and clothed, and whose regularity of conduct is enforced by military 
discipline, which physicians cannot expect among the inhabitants of 
St. Giles in London, and the Cowgate in Edinburgh. Therefore, 
they seldom see pure typhus in their practice; and they will have 
to blame themselves if they often meet with synochus; for they are 
too bold and intelligent, and are too well versed in military tactics, 
not to attack the enemy before he gets possession of their strong- 
holds : and they will rarely be found guilty of declining an engage- 
iu' nt from fear of another enemy which may appear when they are 
weakened by the combat. Soldiers and sailors can very rarely con- 
ceal a fever; so that they are brought at once to the medical officers, 
who, therefore, see the disease early, and before it becomes compli- 
i. A L'reut deal, also, depends upon the treatment pursued in 
the first stage. It' a physician were always afraid in the first stage 
of levers to npply the proper remedies when inflammatory symp- 
toms presented themselves, lest a low or putrid tendency should 
quently occur, he will, of course, frequently see the compound 
ichus" in its worst form. 

I have now to treat, first, of fever from functional derangement; 
■ -•////. fever from inflammation; thirdly, fever from congestion; 
Joint 'h/y, a mixed form ol fever, consisting of a combination of these 
three, but in which congestion generally predominates at last, com- 
monly called typhus and synoehu . 

riVKB PROM FUNCTIONAL DF.RANGEMENT. 

Am. ages and c society are liable to this form of fever; 

but more particularly children, and those who have the inclination 
ami means to overload the stomach and bowels with too much nou- 
rishment. It is not, m general, very formidable; bul eases are occa- 

llly met with which are abundantly alarming, and difficult to 

.tiom the impossibility of fixing upon any one organ which can 

lid to be affected severely, and yet all organs are out of order, 

to considerable constitutional disturbance. In some cases 

j inptoms are exceedingly slight for a week or ten days. The 



118 CONTINUED FEVER. 

patient often feels chilly, which he is apt to attribute to the weather 
— increasing weakness and languor, which he thinks are owing to 
impaired appetite; he has restless nights, with burning heat in his 
hands and feet, and some thirst. At last his whole surface is hot; 
he perhaps goes to stool once a day or even twice, and he passes 
something, which satisfies him that his bowels are right, when all 
the time they are constipated ; and when a medical man is called, 
he will find him much in the following state;— skin parched; thirst 
considerable; tongue loaded with a yellow fur; without appetite; 
and the pulse, perhaps, about 95 or upwards; the urine scanty and 
high coloured. He complains of restlessness, particularly at night; 
and general uneasiness, with oppression at the prcecordia; he has 
slight headache; but complains most of pain in the lumbar region. 
The stools, when examined, will be found fetid, scanty and adhe- 
sive ; or watery and dark coloured, containing small hardened por- 
tions of feces, often mixed with a good deal of mucus. He loathes 
the articles of food which, in a state of health, he most relished, even 
tea and coffee, milk, beer, &c. During the night, his mind wavers; 
if he falls asleep, he appears restless and disturbed, and awakens 
with a start, the effect, perhaps, of a terrific dream; occasionally, 
there is delirium. In some cases these symptoms continue even in 
a slighter degree for fourteen or fifteen days, and at last terminate in 
local congestion, or in inflammation of some organ, and in the end 
assume the type which is termed typhoid; in fact, these are the cases, 
particularly where there is delirium, which many people call "typhus 
mitior." 

Sometimes the fever is very sharp, and there is considerable ex- 
citement, with increased heat, general uneasiness, and delirium; the 
pulse above 100, full and strong; much oppression at the prcecordia; 
the respiration hurried; the tongue loaded, perhaps dry and parched; 
and the bowels very much disordered. 

Treatment. — I have a great dislike to treat this form of fever, 
and for the following reasons: First, the patient has been long ill 
before he confined himself and sought for medical advice. Secondly, 
the symptoms even then are apparently mild, while internal organs 
are seriously impeded in their functions. Thirdly, if inflammation 
have taken place in any internal organ, it is more difficult to treat 
than in pure inflammatory fever, in consequence of the exhaustion 
occasioned by the previous indisposition. Fourthly, nothing can be 
beneficial if the greatest attention be not paid to the moral manage- 
ment of the patient, giving him laxative medicines at regular periods, 
and rigidly withholding improper articles of food. This is the kind 
of fever which is in general cured by confinement to bed; a steady 
perseverance in gentle laxatives, repeated two, three, and even four 
times a day ; quietness and abstinence from solid food. These are 
the cases in which wine is often prescribed by Brunonians, with far 
less detriment than solid food or beef tea. These are the cases in 
which the cold affusion has been so serviceable when used in the 
early stage, because there is as yet no local inflammation. 

Bleeding is certainly not necessary in all cases, but it is service- 
able in many. I have had several cases of this description on my 



FEVER FROM FUNCTIONAL DERANGEMENT. 119 

hands at one time during the autumnal months; and I have chosen 
patients resembling each other as closely as possible in habits, tem- 
perament, &c. Blood has been drawn from some of these and not 
from others, and I never had reason to regret bleeding, but have 
often had to lament not doing it. It may be here mentioned, that 
bleeding is often employed from other motives than to cure inflam- 
mation. It is sometimes employed to moderate excitement, to di- 
minish plethora, to alter irregular determinations of blood, and also 
to remove venous engorgements; but the only period for the lancet 
is the first days of the disease. 

In such cases bleeding may be objected to, as it has been even in 
inflammatory fevers, but I am sure it is safe in a majority of cases; 
and this conclusion has been strongly impressed upon me by observ- 
ing the manner in which this kind of fever, in particular, frequently 
terminates. First, it sometimes terminates upon the appearance of an 
eruption, which eruption is generally urticaria, sometimes erysipelas. 
Secondly, it often terminates by epistaxis. Thirdly, by diarrhoea. 
Fourthly, by profuse night-sweats. And fifthly, by small boils, and 
even abscess. Taking a common sense view, in reflecting upon 
these matters, I cannot help coining to the conclusion, that it is best 
for the practitioner to take the law into his own hand, and to deplete 
in cases which require it, before the strength of the body is reduced 
by the natural effects of diseased action. If in doubt about the pro- 
priety of general bleeding, the practitioner can have recourse to 
leeching ; and in the class of cases now under consideration, the best 
place t<» apply the leeches is upon the abdomen or loins. Experience 
has led me to this practice, even in cases in which, although the 
symptoms ran high, no local inflammation could be detected, and I 
can speak strongly of its success — the number of leeches to be pro- 
portioned to the age and constitution of the patient, as well as the 

rity and duration of the disease. Emetics are very serviceable 
in the first stage of this fever, in order to unload the stomach of any 
crudities it may contain. It has been already stated, that laxatives 
frequently repeated are highly necessary — to an adult I give powders 
ol two grains of calomel, and six or eight of jalap or rhu- 
barb, or a pill with the same quantity of calomel and four grains of 
the compound extract of colocynth. A child of six years old will 
require the same quantity of calomel, and four grains of jalap or 
rhubarb — the dose to be repeated every second, third or fourth hour, 

rding to circumstances, till evacuations are produced, or till a 
fourth dose ha b< en given, when the medicine is to be assisted by 
the administration of mild injections. Fomentations may also be 
applied t" the abdomen. If the body be hot, it should be sponged 
with cold or tepid water, as may be most agreeable to the patient's 
Opiates are rarely admissible in this form of fever. 
In neglected, or ill-treated eases of this class of fevers, affections of 
the brain, or bronchial membrane, are greatly to be dreaded. 



CONTINUED FEVER. 



FEVER FROM INFLAMMATION. 



It will be recollected that, in a former part of the work, the arbi- 
trary doctrines of fever promulgated by different individuals, viz., 
that fever depended upon inflammation of one particular viscus or 
set of viscera, were rejected ; and my own opinion was distinctly 
stated, that inflammation of every tissue of the body, occasionally 
gave rise to febrile disease. 

Symptoms of inflammatory fever. — In this disease the combina- 
tion of symptoms denominated fever is present, and depends upon 
inflammation of an acute or sub-acute nature, of some organ or 
tissue of the body. Cullen's definition : " Heat much increased ; 
pulse frequent, strong, and hard; urine red; the animal functions 
but little disturbed." 

Although this fever sometimes takes plaCe without any cold stage, 
yet it is generally ushered in with a rigor. During the early stage, 
the patient feels drowsy, yet cannot sleep; he is reluctant to move 
from one room to another, from a feeling of languor and debility; 
there are lossof appetite, vitiated taste, thirst, loaded but moist tongue, 
which soon becomes dry; general soreness is complained of, and 
there are nausea and vomiting; headache, and pain in the back; 
occasionally a combination of all these symptoms is present. Some- 
times, after the first rigor, heat of skin, and all the other symptoms 
of fever, immediately set in; on other occasions, there are alternate 
chills and flushes of heat for several days, till at last the heat pre- 
dominates, and is permanent ; the face is flushed, the skin intensely 
hot, with thirst, restlessness, general uneasiness; in most cases there 
is more or less delirium at night. 

It is necessary to observe that the symptoms vary according to 
the organ principally affected ; but in all cases where there is great 
excitement, the breathing is quick and anxious, the belly costive; 
the tongue becomes parched, but it may be loaded, or very red, with 
its papillae much raised — or intensely red only at the tip and round 
the edges; the pulse is generally full, s'rong and bounding, beating 
above 100, perhaps even 130 in the minute ; there is also oppression 
at the praec.ordia. In very acute cases, the skin has been observed 
to be not only parched and burning, but red, making a considerable 
approach towards an exanthematous affection. 

Inflammatory fevers occasionally terminate by haemorrhages from 
different parts of the body, particularly from the vessels of the nose 
and bowels; by diarrhoea— collections of matter in various parts of 
the sub-cutaneous cellular membrane, and by profuse sweats. But 
these natural terminations are not to be depended upon. 

If the fever go on without proper treatment, disease of structure 
ultimately takes place, in severe cases as early as the seventh or 
eighth day; in slighter, not before the twelfth or fifteenth; and in 
still slighter, not till between the twentieth and thirtieth. Whenever 
this event happens, all the symptoms of typhous gravior, with pete- 
chiae, &c. take place, and then the case is called synochus. It has 
been stated that the symptoms vary not only according to the na- 
ture, but more particularly the seat of the disease ; and it is necessary 



FEVER FROM INFLAMMATION. 121 

in this place to give a description of these, which may be made ap- 
plicable to the other kinds of fever. 

There are several general symptoms which are common to a great 
number and variety of diseases; as headache, heat and dryness of 
skin, thirst, nausea, restlessness, anxiety, oppression at the prcecordia, 
dyspnoea, scanty urine, small fetid stools, &c; bnt there are some 
symptoms which particularly announce disease of particular parts. 

If the brain he affected with inflammation, the symptoms will vary 
according as the inflammation affects the membranes, or the sub- 
stance of the brain itself. If the membranes, there will in general 
be delirium, increase of strength, so much so, that it will require 
some rare to keep the patient from starting out of bed ; the eyes 
vascular, with the pupils contracted or dilated, and the countenance 
may present a ferocious expression ; the patient will, perhaps, com- 
plain of pain of head, by gesture if he cannot by words; the caro- 
tids will throb; there will be great restlessness. The face is not 
always flushed ; it is sometimes pale; the pulse will be various, the 
tongue dry, and perhaps in constant motion. Subsequently, start- 
ing of Ihe tendons, picking. the bed-clothes, and sometimes convul- 
sions, take place, particularly in young subjects; the patient shows 
a disposition to sleep, and then becomes comatose, which state gra- 
dually increases ; the pupils are dilated, and squinting often occurs. 
The respiration becomes more and more rapid and irregular, with an 
occasional interruption, immediately followed by a sigh; the pulse, 
which hid been (puck at first, and had afterwards become slower, is 
now again rising in frequency; it is irregular, and intermits. The 
coma becomes more profound, and death takes place, with or without 
convulsions. 

If the substance of the brain be inflamed, the heat of skirt may not 

creased; the pulse may fall under the natural standard ; perhaps 

it will beal dO or 50, and I have seen it even slower. The extremi- 

11 iy be in constant motion or not ; they may be rigidly contracted, 

particularly the forearms, or if not so, they become contracted the 

moment the arm is touched even to (feel the pulse. The rigidity may 

infined to one arm wnh or without paralysis; the pupils are 

lilated, and the eyelids half or fully open ; sometimes one 

18 shut and Ihe other open; the tongue is not dry till towards the 

last stage of the dlsea 

In both varieties the respiration is much in the same state. The 
bowels are generally bound, and when stools are procured they are 
d involuntarily in bed, as is the urine; sometimes the bladder 
its powers completely, and becomes greatly distended. 

I lungs be affected, the respiration will become more laborious; 

there may be cough, with more or less expectoration; the patient 

complain ol a sensation of rawness under the sternum and id 

the windpipe; or perhaps a stitch in the side may be felt; but hen*, 

«.; affections of the cheat, we must make use of our ears in 

addition lo Ihe oiler Byinpioras, in order to discover whether any 

inflammatory affection i^ going on in the respiratory organs. The 

ihe grand discovery of auscultation will be stated 

DlOre rhen treating Of the diseases Of the chest; but it may 

11 



122 CONTINUED FEVER. 

be now mentioned, that even before I had been much used to the 
stethoscope, I was enabled to point out "primary local affection" 
to exist in the lungs, in cases which were supposed to present the 
pure idiopathic fever. 

If the seat of the inflammation be within the abdomen, it will in 
general be announced by one or more of the following symptoms: — 
pain, increased on pressure ; but it must be remarked, that when the 
mucous membrane of the intestines is the seat of the phlogosis, fre- 
quently little or no pain is experienced even upon pressure. The 
patient will prefer that position in which the abdominal parietes are 
most relaxed; there is more or less tympanitis; and the heat is 
greater over that part of the body than any other. Nausea and 
vomiting are more or less severe ; the patient drinks large quantities 
of cold fluid, although he knows it will produce an increase of pain, 
and, perhaps, will be immediately vomited. The most extensive 
inflammation, and disorganizations of various kinds, may be going 
on in the mucous membrane of the stomach, and bowels, without 
producing redness of the tongue or elevation of the papillae. Never- 
theless, when the tongue is in that condition, or when it is covered 
with small ulcers, or numerous fissures, or when it looks red and 
glazed, or as if skinned, with or without patches of white fur, we 
are enabled to determine that the lining membrane of the alimentary 
canal is in a diseased condition. 

Appearances on dissection. — It may safely be said that there is 
not an organ or tissue of the body which has not been seen disor- 
ganized in fevers, and particularly in inflammatory fevers ; and after 
what has been stated, and from circumstances which are still to be 
stated, it is thought unnecessary to dwell at present on this subject. 

Treatment of inflammatory fever. — Sydenham, whose works 
are among the greatest ornaments which medical literature possesses, 
recommended, above a hundred and sixty years ago, the same, or 
nearly the same practice, which stands good in the present day. He 
was led by his great wisdom and experience into a proper line of 
treatment, although he had not the advantage which we enjoy, of 
examining morbid appearances after death, to confirm his views. He 
had erroneous notions, it is true, in consequence of his imperfect 
acquaintance with morbid anatomy, but he was the first who pointed 
out the impropriety of treating all fevers alike, by showing that differ- 
ent organs are affected in different cases. He pointed out also very 
precisely, that a fever requires different treatment in every stage as it 
advances. He likewise made pointed observations against the far- 
rago of medicines which were generally prescribed, and his own 
plans were exceedingly simple. It was- he who first introduced the 
plan of purging in fevers. His chief hope seems to have been on 
the lancet, laxatives, and opiates, the strict antiphlogistic diet, and 
allowing no solid food. If he could have proved his opinions by an 
appeal to dissections, it is probable there would not have since been 
so many changes in practice. 

An emetic followed by gentle laxatives; a bland liquid diet; small 
doses of solution of the tartrate of antimony; and perfect quietness, 
will produce a cure in very slight cases. But in severe cases, it is 



FEVER FROM INFLAMMATION. 123 

necessary to open a vein, and take away as much blood as will make 
an impression upon the disease, without reference to quantity. Young 
practitioners are often prevented from using the lancet, because there 
is no decided fixed pain; but they may rest assured, that in fevers, 
and more particularly in inflammatory fevers, some internal part in 
particular is. suffering, although it does not exactly appear to their 
inexperienced eyes. Local inflammation is often concealed by the 
general irritation and uneasiness which prevails; and it does not 
show itself to a superficial observer till it has become very severe. 
But we must not bleed in the manner recommended by the French, 
at least in inflammatory fevers. Boisseau, urging the necessity of 
general bleeding, says. p. 99 of his work, entitled Pyretologie Phy- 
siologique, ed. 1S24 : " Less than S ounces should not be taken at 
each operation ; but this quantity will rarely suffice; it is necessary 
in general to draw 12 ounces; one may carry it even to 16 ounces, in 
subjects of whom I shall speak, but one ought never to exceed this 
quantity. It is better to repeat the bleeding." I would also beg 
to refer to the cases and dissections published by M. Andral, in the 
1st vol. of his Clinique, in which the deplorable effects of similar 
undecided practice are too evident to require being pointed out. 

The causes of the failure of bleeding in this, and other diseases, 
are : First, most physicians order the precise quantity of twelve or 
sixteen ounces of hlood to be taken from all adults, without reference 
to sex, age, peculiarities of constitution, or the actual pathology of 
the disease. Secondly, By the long period which is allowed to 
elapse between the bleedings, the strength is diminished, valuable 
time is lost that cannot be recalled, while little progress is made in 
eradicating the disease. Thirdly, No difference is in general made 
between bleeding a plethoric individual, and one who is in the op- 
posite condition of system. Fourthly, The period of the disease 
influences a pathological physician, while it does not one who never 
looks at tin- inside of a dead body. Fifthly, The good effects of a 
general bleeding are very frequently lost, by not following it up, in 
proper tira nation; or by local bleedings, which 

;ir>- often found t<» he most efficacious. Sixthly, The good effects of 
ling are often malted by neglecting to employ contra -stimulation 
ami contra-irritation, as veil as by loading the patient with too many 
ithes, and by errors of diet. 

The patient should he seen within a few hours after the first 

ling, and the operation should be repeated at a short interval, if 

If this he done, particularly if followed by laxatives, blis- 

ind the use ol the tartar-emetic, it will rarely he necessary in an 

inflammatory fever, however acute, to bleed a third time. But if, at 

•owl or third visit, we find the patient so well as not to require 

further lovs of blood, we are not to conclude that he is out of danger; 

ami it is necessary to impress upon the minds of students and young 

practitioners, that if they are to do L'ood in such a ease, the greatest 

attention must he paid at the very commencement of the disease: 

vigilance ai this period will save much subsequent trouble and anxi- 

When leeches are necessary, they should be applied as near the 

-it as poniblej which is generally the epigastrium, the ileo- 



124 [CONTINUED FEVER ] 

coBcal region, or the brain. With regard to antimony, objections are 
very justly entertained against its use, when the stomach and bowels 
are either irritated or inflamed. 

[We propose, in this place, to make a few observations on the 
treatment of fevers in general, and especially in respect to the stage 
of exacerbation. There can be no question lhat the latter is often 
aggravated by the improper or ill-timed interposition of medicine; 
and it should be the constant object of the practitioner to quiet the 
irritation and preserve the retentiveness of the stomach by every 
possible means. With this view, the whole class of diaphoretic 
remedies is objectionable, until the active symptoms are allayed or 
mitigated. When we may venture upon their use, they should be 
given in very limited doses and carefully watched in their effects. 
One of the safest of these preparations is the effervescing draught, 
(prescrip. 60,) or the solution of citrate of potassa. Two drachms of 
the latter dissolved in six ounces of water with a little sugar and two 
or three drops of the oil of lemon, constitute one of the least irritating 
and most efficacious formulae, to which a little spirits of nitre may be 
added or not, according to circumstances. A tablespoonfnl, or half 
that quantity may be taken every two hours. The best mode of 
administering tartrate of antimony is to give the twentieth part of a 
grain dissolved in water, at the intervals just named. The action of 
either of the above preparations may be much augmented by adding 
small quantities of sulphate of morphia, or any other preparation of 
opium to each dose, and especially where there are restlessness and 
want of sleep. But if these or any other medicines are found to 
occasion heat or other distress in the region of the stomach, or to add 
in any degree to the general excitement, let them at once be discon- 
tinued. It is far wiser to administer no medicine whatever, than to 
give it to the manifest aggravation of disease. The anxiety of the 
physician to do something, or of the patient or his friends to have 
something done, is often one of the greatest obstacles to the manage- 
ment of fever. If active general remedies are promptly used in the 
incipient stage of inflammatory fevers, as our author has judiciously 
advised, the resort to any plan of coercive internal treatment will be 
unnecessary; and, on the contrary, mild, persuasive measures, com- 
bined with repose, and the exclusion of the ordinary sources of phy- 
sical and mental excitement, will, in the great majority of cases, 
lead to a favourable termination of the febrile symptoms. These 
truths cannot, I conceive, be too often or too emphatically repeated; 
and they are, if possible, yet more applicable to the fevers of infancy 
and early childhood, wherein diagnosis is often conjectural, because 
the patient cannot convey by language any idea of the nature or seat 
of disease. 

If there be heat and thirst, give cold drinks freely, as our author 
has advised. Is there sickness, or irritability or pain of the sto- 
mach ? apply leeches, or cups or a blister to the epigastrium, and give 
the patient ice in small pieces. Is the head painful and the skin hot? 
In addition to any applications to the part affected, let the feet and 
legs be immersed in a tepid bath, for twenty minutes or half an hour; 



CONGESTIVE FEVER. 125 

and repeat this as often as it affords relief or is grateful to the patient. 
Pediluvia to be efficacious should be prolonged. 

If the bowels are confined and the siomach irritable, resort to simple 
enemata; if the skin is hot, let them be of cold water in large quan- 
tity; and by frequently sponging the limbs and head with the same 
element, much may be accomplished towards the mitigation of dis- 
tress and the abatement of disease.] 

Some practitioners do not allow their patients to use fluids freely, 
particularly cold drinks; but I believe this is a most injudicious pro- 
hibition, and that they may, in general, be allowed to gratify them- 
selves in this respect. 

The practitioner should be regular in his visits in all acute cases, 
as sick people watch the hours, and become impatient and dissatisfied 
till he makes Ins appearance; and he should be careful how he ex- 
presses himself, for one word, or even a slight alteration of counte- 
nance, may rob the patient of all hope. 

When the state of collapse comes on in fever, the patient should 
be carefully watched, that he may have his nourishment and medi- 
cines at proper intervals, and that the heat of the body may be pro- 
perly supported. 

Stimulants are frequently necessary at the termination of this class 
of fevers; but nothing in the practice of medicine is more difficult 
than to determine, whether astimulant given in such a case is to do 
harm or good. When it is given, let it be in small quantity, closely 
watching the effect. If I were compelled to state, whether more 
mischief would follow the exhibition of stimulants in every case, or 
withholding them, I could safely say, that giving them in every case 
would be highly prejudicial. For although marked benefit is some- 
times produced by stimulants, yet I have more frequently observed 
mischief; they are most beneficial when exhibited to patients with 
either a compressible, or a very quick and irritable pulse, and to those 
who experience profuse perspirations. 

CONGESTIVE FEVER. 

Tins is a fever, in the most severe form of which the pulse and 
the heal Of the skin are generally below the natural standard. In 
slighter cases, the extremities are cold, or have a tendency to be 
. while the heal of the trunk of the body is increased. The best 
I spies of congestive disease, are to be found in those individuals 
who die m the cold stage of the intermittent and yellow fevers.* 
The existence of congestion is well displayed in the first stage of in- 
termittent lever; and I have sen many cases of pure congestive 

fever succeed die cold stage of an intermittent, when fail reaction 
could not develop itself. 

-live fever is a common form of disease in this climate, and 
is usually denominated u typhus." It is a disease which Sydenham 

• Bel in I K.i'l .-in ..;■(• irtonlty of log the Adriatic cholera, and examining into 

■ i was led u ■ be ibe purest example ol 

i rror of ibia opinion when treating of that disease in 

Ike pi pel place. 

!!• 



126 CONTINUED FEVER. 

knew well, and treated in the most judicious manner.* After stating 
that the invention of the term "malignity," has been far more destruc- 
tive to mankind than that of gunpowder, he describes as decided a 
case of congestive fever, as is to be found in any modern work. 

This case proves, beyond all doubt, that Sydenham must have had 
very good notions of the pathological condition of the body, from the 
expressions he uses, as well as from the practice he employed. 

" But if it be inferred," says Sydenham, " that there is some ma- 
lignity in the case, not only from the purple spots, but also from 
finding the symptoms of fever milder sometimes than should seem 
agreeable to its nature, whilst, notwithstanding, the patient is more 
debilitated than could be expected for the time — I answer, that all 
these symptoms only proceed from nature's being, in a manner, 
oppressed and overcome by the first attack in the disease, so as not 
to be able to raise regular symptoms adequate to the violence of the 
fever; all appearances being quite irregular. From the animal eco- 
nomy being disordered, and in a manner destroyed, the fever is 
thereby depressed, which in the true natural order generally rises 
high. I remember to have met with an instance of this kind, seve- 
ral years ago, in a young man I then attended ; for though he seemed 
in a manner expiring, the outward parts felt so cool, that I could not 
persuade the attendants he had a fever which could not disengage 
and show itself clearly, because the vessels were so full as to obstruct 
the motion of the blood. However, I said that they would soon see 
the fever rise high enough upon bleeding him. Accordingly, after 
taking away a large quantity of blood, as violent a fever appeared 
as I ever met with, and did not go oft till bleeding had been used 
three or four times." 

This disease has been described by several tropical physicians, 
but particularly by Dr. Jackson; and it was in warm climates that 
I first obtained correct notions upon the subject. But the profession 
is much indebted to the late Dr. Armstrong, for the very excellent 
manner in which he has illustrated its nature and treatment. 

Symptoms of congestive fever. — We shall find, upon inquiry, that 
the patient has had a threatening of indisposition for perhaps ten 
days, a fortnight, or even three weeks, previously to confining himself 
— that his appetite has been gradually impaired, with irregular action 
of the bowels; and that he has occasionally complained of alternate. 
chills and flushes of heat, till at length the chilliness prevailed. This 
is the history which we in general receive of the progress of the 
severe cases. Even in mild cases, the heat of the skin is diminished; 
the pulse is weakened, or it is oppressed, and beats, perhaps, not more 
than 50 or 60; the prostration of strength is very considerable; the 
tongue is in general moist, and more or less loaded ; the patient is 
lethargic, rather than comatose, though coma may subsequently take 
place; he can be roused, but the sensibility is evidently diminished; 
he complains of giddiness, confusion of intellect, heaviness, pain or 
sense of weight, either at the crown of the head or forehead. The 
general functions of the body will be found to be more or less im- 

* Swan's edit. p. 567. 



CONGESTIVE FEVER. 127 

peded ; but disturbance of some particular organ, in general, mani- 
fests itself, and the symptoms must of course be thereby considerably 
modified, as in other febrile diseases. In congestive fever, as well 
as in others, the brain may be the seat of disease in one person; the 
lungs in a second ; the liver and mesenteric vessels in a third ; and so 
on, the disease being essentially the same, but modified according to 
the principal seat of the congestion. 

In congestive fevers there is generally a peculiar expression of 
countenance — it looks besotted; the manner of the patient is unde- 
cided, with an appearance of carelessness, and his words seem, as it 
were, to hang in his mouth ; the cornea look's dim; the pupil, in the 
first stage, is rather dilated, and is not much affected by light. If 
the patient attempts to walk, he staggers like a drunken man. There 
is always more or less prostration of strength, and in severe cases, 
he is unable to stand upon his legs, or to move his hand to his head, 
even from the first. The respiration is short, quick and weak. He 
often signifies that he has a great load in the precordial region. As 
the disease advances, he becomes more and more comatose; picks 
the bed-clothes; and is always found lying upon his back, slipping 
down by imperceptible degrees to the foot of the bed: the surface 
becomes more cold ; the breathing more difficult ; the face assumes 
a leaden hue; and, occasionally, though rarely, convulsions take 
place; sometimes there are nausea and vomiting, and sometimes 
diarrhoea; most frequently, however, the patient is constipated. 

It may be shortly mentioned, that the appearances on dissection 
are much the same as those described in intermittent fever. 

Wiih respect to the causes, they are the same as in other fevers; 
but I have seen several very severe cases produced by bathing in 
the sea, and remaining too long in the water; by taking a drink of 
cold water; and by a weakly person exposing himself to a damp 
Cold wind, when his body had been previously heated. 

Pathology of congestive fever. — No one can tell which is the 
first link 111 the chain of diseased action. The balance of the circu- 
lation may be destroyed, and congestion thereby produced, upon 
hearing disastrous news, which some say, proves that a peculiar 
action in the brain is the first phenomenon; but then, exactly the 
same circumstance may happen from taking a cold drink, or remain- 
ing 100 long iii the water when bathing. Therefore it must be 
confessed tin-re is much ambiguity about this part of the pathology, 
lint it is unnecessary to go over the same observations which were 
made when treating of intermittent and other fevers, further than to 
shortly, that when the head is the clurfscat of congestion, there 

early Bymptoms of lethargy, coma, and a diminution of sensi- 
bility, frequent chills, followed by other well-known nervous .symp- 
toms, and occasionally by convulsions. When the heart and lungs 
ean oppressed, irregular, or intermitting pulse; 

tk sud hurried respiration ; cough ; marks of impeded circulation 
in the face, and a difficulty in supporting the heal of the body ; and, 
m some r ire c ises, violent pun in the region of the heart, and along 

the arms, is complained of. It may bfl lemai lied, that whenever llie 
pulse (bell weaker than natural in a severe disease, it is an excellent 



]28 CONTINUED FEVER. 

plan to place the ear to the region of the heart, for we shall often 
find it acting most powerfully when the pulse is weak in the ex- 
tremities. When the congestion affects the viscera within the abdo- 
men, there is generally a sense of fulness and distension about the 
stomach ; the bowels are irregular, being either too loose or bound ; 
and in either case, when stools are procured, they are found to be 
clay-coloured and very fetid, with very little bile, or very dark. 

This opportunity may be seized for the purpose of noticing the 
most probable means which the animal system possesses, to prevent 
the balance of the circulation from being lost. First, There is a 
power possessed by all animals, of preserving to a certain extent a 
proper degree of heat under every condition of atmospheric, vicissi- 
tude—thus the heat of the body is not a degree higher under a burn- 
ing tropical sun than in this country, which so far prevents cold from 
producing a lost balance of the circulation. Second, The elasticity of 
the coats of both arteries and veins, tends also to prevent the state 
of congestion, because they are capable of considerable distension, 
and are still contractile. These are assisted by the free anastomosis 
which subsists between the vessels of a part. This is well illustrated 
by the experiments which have been performed on the frog's foot, 
to determine the nature of inflammation. When a part is first 
irritated, the momentum of the blood is greatly increased ; at last a 
vessel becomes obstructed, a globule of blood cannot pass through it, 
but it is seen to make a retrograde movement, and to find its way by 
another branch. 

The pathology of this fever is happily illustrated by comparing 
the symptoms with the phenomena which occasionally take place 
in eruptive fevers, and to which I shall now make only a short allu- 
sion. In some cases, when the eruption is tardy in making its ap- 
pearance, alarming symptoms, and even convulsions, take place. 
After the eruption has made its appearance, it sometimes suddenly 
and prematurely disappears, when congestive symptoms occur. Let 
the inquirer ask himself, where has the blood receded to, which a 
moment before rendered the skin as red as the shell of a boiled 
lobster? 

Treatment of congestive fever. — In considering this part of the 
subject, it is very useful to remember the efforts which are made by 
the powers inherent in the constitution to remove internal accumu- 
lations of blood, if they be in any way short of that degree which 
kills the patient instantly. The first of these, and the most common, 
is the state which in medical language is called reaction, which in 
its turn may create inflammation of the organ most affected with the 
congestion. We have next increased secretion, as a natural means 
of removing the congestion. 

In the treatment of all diseases, the physician has to determine 
whether it will be most advisable to leave the case to the natural 
efforts of the constitution, assisting them a little in their operations, 
or whether he is by a bold decisive measure to step in to relieve the 
system at once. In this case, he is apprehensive that the heart and 
other vital organs may be too much overloaded and oppressed to 
create full reaction, or that the system will sink under the task. He 



CONGESTIVE FEVER. 129 

has also to fear the effects of die reaction, which may terminate in 
extensive local inflammation. Anxious to escape these evils, he will 
follow the plan pursued by Sydenham in the case recently quoted, 
and he will open a vein with a view of at once restoring the lost 
balance of the circulation. The quantity of blood necessary for this 
purpose, in any given case, cannot he previously estimated. A 
Stimulant may be at the same time necessary to rouse the action of 
the heart a little, and make the blood flow from the orifice. I have 
frequently proved, before a number of witnesses, that it is not in- 
consistent with good pathology to bleed and stimulate at the same 
time. 

When a vein is opened, the blood will, perhaps, only trickle down 
the arm at first; on other occasions it will spring from the orifice in 
a large stream, and suddenly stop before a table-spoonful is evacu- 
ated. Some think this is owing to an alteration in the position of 
the arm— others, lo the tightness or slackness of the bandage. Phy- 
ins frequently attribute this phenomenon to debility, and they 
take it aa the most certain sign that the patient will die in their hands, 
were they lo carry the operation farther. But it must be recollected 
that the blood is moving very slowly in the arteries, while the veins 
I When an opening is made in the vein, it suddenly 
empties itself, and as a supply is not quickly at hand, it is some time 
before the blood begins again to flow. Let the finger be placed on 
the orifice, the vein will be filled, and the blood will spring again. 
Heat is also to be applied, and, if possible, the patient should be 
placed in a warm bath; if that cannot be obtained, the feet and legs 
Bhould be plunged into very warm water, and hot bottles placed 
round the body. The patient is to be rubbed with stimulating fluids, 
as heated spirits of turpentine, and aqua ammoniac; drachm 
a of ether may be given, or a solution of the carbonate of am- 
monia, in the proportion ofeighl or ten grains to an ounce of water. 
II- Bhould be encouraged to drink warm fluids. The caution and 
riminaiion winch ought to be pursued in drawing blood in such 
critical circumstances, need not be insisted on; Buffice it to say, that a 
stimulant ought to be •''' hand, and a finger should be on the pulse 
of the opposite arm, to watch the effects of our practice. 

i well alter the bleeding, the bowels being in 
a proper state, two grains of calomel and one of opium may be given 
in a pill, ami repeated every three or four hours. 

General bleeding is admissible only in the earliest stage of con- 

ive lever, unless in cases in which the pulse is still strong and 

lull. Should the proper ijme for venesection have passed, stimulants 

are sometimes found serviceable, but must be administered with 

>n, and relinquished for perhaps debilitating remedies, upon the 

first appearance of reaction. If, at any tune in the subsequent pro- 

o| the e 186, there should appear signs of local disease, the ap- 

plication of leeches and blisters should he had recourse to; and iho 
.1 is lo !..■ treated during convalescence in the same manlier as 

in any OtllOl !■ \\ ■ i. 



130 CONTINUED FEVER. 



MIXED FORM OF FEVER BETWEEN THE LAST MENTIONED THREE, 
BUT IN WHICH CONGESTION PREDOMINATES. — THIS IS USUALLY 
DENOMINATED TYPHUS AND SYNOCHUS. 

In the disease which is now to be sketched, there is a combination 
of the last three described fevers, appearing under three forms: 

1st, Severe cases of congestive fever, in which there is slight or 
suppressed reaction, followed by inflammation. 

2d, The functional fever, subsequently united with congestion, and 
consequent accumulation of blood in different organs; this forms, I 
apprehend, the typhus of authors. 

3d, The inflammatory fever, subsequently united with congestion ; 
this is the synochus of authors. 

As to the first variety, it has been fully explained in the last article, 
and the same remarks need not be here repeated. 

The second variety begins in the manner wbich has been already 
described in fevers from functional derangement, but subsequently, 
an accumulation of blood takes place in the centre of the system. 
When the circulation becomes so much embarrassed, all the symp- 
toms of congestive fever take place, the patienthaving been debilitated 
by the previous diseased action. 

The third variety commences in the manner which has also been 
already described in inflammatory fevers, but subsequently the ba- 
lance of the circulation becomes more and more lost, and congestion 
follows ; in which state of the system, the inflammatory action is sup- 
pressed, but not extinguished. This takes place when debility and 
exhaustion have been already produced by the previous disease. 

The brain, lungs, and organs in the abdomen, are liable to be im- 
plicated, and in the worst cases which occur, they generally are all 
affected, either simultaneously or in succession. Hence there is a 
complication of symptoms, and as the disease principally affects the 
poor, who are ill-clothed and badly fed, and as medical advice is not 
in general sought during the first stage of the disease, we usually 
find it very difficult to manage. 

In the early stage of the second variety, and when alone any thing 
like active practice should be had recourse to, the symptoms certainly 
denote debility, which are as yet occasioned by oppression and ob- 
structed action only; and often have I seen cases immediately and 
permanently benefited by drawing blood, in which, had the opera- 
tion been postponed for twenty-four hours, it would have been quite 
inadmissible. It may likewise be remarked, that much of the op- 
pression and debility also depends on the condition of the lungs, 
which, besides being congested, and therefore unable to perforin their 
functions properly, are subsequently still further embarrassed by an 
inflammatory affection of the bronchial tubes. Both these conditions 
tend to prevent the changes in the blood, which are well known to 
be elaborated in the lungs; therefore, all organs must suffer addition- 
ally, and the brain of course among others. The bronchitic affection 
in fever has attracted my attention for many years, and I am led to 
believe, that i'ew instances of febrile affections take place without 



TYPHUS AND SYNOCHUS. 131 

bronchitis appearing in some stage of the disease, and very often it 
is the primary affection. In all the fevers which are called putrid, 
and which are accompanied by dark-coloured spots on the surface of 
the body, termed petechias, it will be found, I am almost inclined to 
say invariably, that bronchitis prevails to a great extent. The some- 
what livid and circumscribed redness which is seen so often on the 
cheeks in the fevers called typhoid, is principally owing to the embar- 
rassed state of the lungs; and exactly the same circumstances take 
place in synochus. 

In the third variety, bleeding maybe had recourse to with benefit, 
later in the disease than in the others, and often have I seen it decid- 
edly beneficial when cases were going wrong under the injudicious 
use of stimulants and tonics. In proof of these statements, the reader 
is referred with confidence to Dr. Mason Good's account of typhus, 
in his second volume, (from page 230 to 25S.) According to his 
views, this, bring m a disease of sensorial debility, leading on to pu- 
trescency," is to be treated by tonics; " bleeding and purging are 
among the foremost objects of prohibition." Nevertheless, in the 
next page, the following contradictory statement is advanced ; "hence 
the fever will lie aggravated from local irritation, and the affected 
organ will be in danger of inflammation, if not of gangrene." 

There is no class of diseases in which the stethoscope is of more 
practical advantage than in fever ; for, as has been already mentioned, 
the heart may be found beating violently, whilst the pulse at the 
wrist is so weak as scarcely to be felt, and when symptoms of gene- 
ral debility appear to be very great, and the extremities cold. To a 
patient in such a slate, most medical men would naturally be led to 
give wine, beef tea, and animal jellies, which they would not do if 
they were aware that the action of the heart was strong. During 
tin: last twelve years, I have seen many severe cases of fever, in 
which marked benefit was produced by withdrawing stimulants, and 
tlie patients have ultimately recovered after being leeched and blis- 
tered. Lei it not, however, be supposed that I am an enemy to 
siiiniil mis 111 all cas.s <>| fever ; oil the contrary, 1 have seen patients 
ionally snatched from the grave by their judicious employment. 
What i> wished i<> be impressed upon my readers is, that in all fevers 
we have i.i dread local congestions ami inflammations more than 
debility and putridity. That I am in the habit of using stimulants 
in fever, I can appeal to the gentlemen who have been my pupils, 
ami who have witnessed my practice, who can at the same time 
verify the following statement: — that much mischief has occasion- 
ally followed, ami that therefore I feel fully as anxious about the 
' nf a stimulant as of bleeding. When a .stimulant is necessary, 
wmr is the best ; ami experience has taught me, that wine, or any 
Other Blimulant, is far less likely to do harm than beef lea and animal 
jellies. 

no doubl can bo quoted, whore stimulants, in large <|uauli- 

h ive been administered from the beginning of the disease, and 

die pan- nis have recovered. But the lest way for any one to come 

tn right conclusions regarding tins question, is, to judge from the 

ral result of what lie has himself seen. I have had many op- 



132 CONTINUED FEVER. 

portunities of observing that recoveries were slower, and relapses 
more frequent, in cases treated upon the stimulating plan, than the 
antiphlogistic. 

Emetics cannot be too highly extolled in the last stage of some 
cases of fever, particularly the varieties called typhus and synochus, 
but only in those in which the bronchial tubes become filled with 
muco-purulent matter. This happens in consequence of the patient 
being too long asleep, or not coughing up the matter before too great 
an accumulation has taken place. Many of my friends have seen 
the happy results of administering emetics in such cases, and more 
particularly, my dispensary pupils will not forget many instances of 
this among our poor patients during the late epidemic fever in Edin- 
burgh. 

Cleanliness, free ventilation, and quietness, are three great and 
essential circumstances to be attended to in the treatment of fever. 
The alvine evacuations should be removed instantly out of the room; 
and it is of great consequence to attend that the quantity of bed- 
clothes be not too great in the first and second stages of fever when 
the skin is parched, or too small when the patient is approaching to 
the state of collapse. The extremities should be examined at every 
visit by the physician, as sometimes the symptoms are aggravated 
in consequence of cold limbs, which will perhaps require no other 
remedy than the application of heat. The state of the bladder 
should be attended to, for although the urine is generally suppressed, 
yet occasionally it is not so. The temperature of the room can 
scarcely be too cold in the first stages, but much injury has been 
produced by keeping it too low in the stage of collapse. Many 
patients have been strikingly benefited in less than half an hour 
after their bodies were made warm, and perhaps their lives ulti- 
mately saved without the assistance of any other means. Some 
owe their death to being removed from a warm and ill-ventilated 
room into the cold ward of an hospital; so frequently has this hap- 
pened, that I am obliged to run all hazards from bad air, bad nursing 
and filth, rather than send my patients to the infirmary of Edinburgh, 
which is ill constructed for any class of patients whatever. The sick 
are also badly classified, which is, perhaps, no fault on the part of the 
medical attendants, who ought to be well aware that the tempera- 
ture of a ward calculated for fever cases in the first stage, is too cold 
for those in the last. Every fever ward of great extent should be 
warmed by means of heated air, and provided with water closets for 
the use of convalescents. 

For a considerable time it baffled me to account for the discrepant 
histories of fever which have been handed down to us, and for the 
confidence with which opposite practices have been recommended 
to our notice; but further experience has convinced me, that this 
discordance of opinion may be accounted for by one or other of the 
following circumstances: 

1st, A difference in the character of the prevailing epidemic, and 
the constitutions of the persons affected; for example, a functional 
fever will bear stimulating remedies which would kill a person la- 
bouring under an inflammatory fever, particularly if the iuflamma- 



TYPHUS AND SYNOCHUS. 133 

tion affected a vital organ. A stimulant given in congestive fever 
may operate beneficially; whereas, in functional fever, or in inflam- 
matory fever it would be very injurious. A well fed, and previously 
healthy soldier, who has no cares, will in general have a high-toned 
fever; whereas a poor, ill-fed, and badly clothed labouring man, 
worn ont by cares and anxieties, and living in an ill-ventilated and 
filthy apartment, will be affected with one of an opposite character. 

2d, An arbitrary and too often empirical practice, which has 
hitherto been too frequently followed. One physician always bleeds 
in every^ase of fever — another stimulates; and when the results are 
analyzed, perhaps it will be found that the proportion of deaths is 
the same, and even these results will vary to support the one practice 
or the other, according to the habits and constitutions of the patients : 
for instance, if our army and navy surgeons were to stimulate 
throughout the course of the fevers they have to deal with, they 
would scarcely save a patient; and if practitioners, entrusted with 
the care of the sick poor, were to bleed all their cases of fever, they 
would be quite as unsuccessful. 

lid, Writers are too often guilty of an error which all medical men 
are liable to commit, viz., of mixing up their own opinions with 
matters of fact in their statements. 

•I///, The prevailing habit of drawing sweeping conclusions from 
one or two facts. 

5th, Unphilosophical attempts to bolster up erroneous views by 
special pleadings. 

The proportion of deaths in fever, in my dispensary practice, from 
the beginning to the termination of the last severe epidemic in Edin- 
burgh, was as follows: — Out of the first hundred and forty cases, 
was only one death. This patient was anxiously attended by 
a highly respectable practitioner in this place, who was then my 
I mi; he died during a relapse after he had sat up. The pro- 
portion <>!' d'-ailis, however, subsequently increased, so that in No- 
vember 182*7 the calculation of deaths was 1 in 97. This includes 
ll individuals who were in Ihe last stage before we were 
applied to; also ihe case of a girl who died during a relapse from 
accidental loss of blood alter the application of leeches ; an old lli^h- 
lander, who would take no other medicine than his own mountain 

dew ; ami an old woman, above 60, who, when convalescent, took 
a shivering lit and died immediately. 

The appearances found on dissection, in our fatal cases, wore as 

follows: — In two eases there was well marked arachnitis, viz., by ex- 

e effusi >f coagulahle lymph, which was deposited between 

H hnoid and dura mater. In both there was greal vascular 

lurgt Hie effusion into the ventricles ; ami in one ol these 

there u- is white ramnllissemenl in the centre of the brain. In two 
men, and on.- old woman, ihe vessels of the brain were found very 
much gorged with blood and the pja mater, throughout its whole 
extent, had its vessels ainarziugly distented with dark blood. The 
preparations were dried on L-iass, uu >\ can even now he seen in tins 
stale In these three last-mentioned cases there was some effusion 

DOder the arachnoid, ami the ventricles ; and on slicing the brain, 
1 J 



134 CONTINUED FEVER. 

an unusual number of large bloody points were observed: there was 
also bronchitic effusion, and in one of them a considerable portion 
of the lungs was in a state of softening and intensely red. In the 
old woman, who died so suddenly during a rigor, when apparently 
convalescent, there was little disease in the mucous membrane of the 
stomach and bowels; but in one of the men, there was extensive 
vascularity of this membrane, but no ulceration ; the mucous mem- 
brane of the stomach corrugated, and the whole of the splenic ex- 
tremity was studded with red points, which were seen through a 
great quantity of thick viscid mucus, which, being washed^ff, and 
the stomach stretched, these red points were discovered to be vessels, 
which existed in immense numbers ; the vascularity was greater, 
however, in the mucous membrane of the bowels, particularly 
throughout the whole of the ileum, and a great part of the colon. 
In the other man, when the abdomen was opened, the small intes- 
tines had a black appearance, as if in a state of mortification; they 
were found filled with a bloody-looking exudation, which, from its 
weight, had borne them down into the cavity of the pelvis. It was 
thought at first that this matter was the sole cause of the discolora- 
tion ; but, upon cutting open the intestine, it was found that they 
owed this colour principally to great vascularity; there were no 
ulcerations. There are dried preparations, and drawings of the ap- 
pearances in this case, in my museum. In other cases, there were 
ulcerations in the ileum and colon, of which also the preparations 
and drawings are in the museum ; and I am inclined to believe that, 
if these appearances were properly looked for, they would be more 
frequently seen. In one case, the left kidney was enlarged, as well 
as the ureter; its pelvis, on being cut open, was found to contain 
about six ounces of pus, and the inner membrane was very vascular. 
In the body of the old woman, who, it has been above stated, died 
suddenly during convalescence, the diseased appearance was, that 
both lungs were found as black as they usually are when affected 
with melanosis. I was not at the dissection, being engaged at the 
time in delivering a lecture; but Dr. Crellin, who conducted the 
examination, sent for me, and it was proved to the satisfaction of all 
present, that this appearance was not melanotic, but produced by 
venous engorgement. I had never before seen the whole of both 
lungs so completely engorged ; they sank in water, but after being 
washed, they regained not only their natural appearance, but their 
proper degree of buoyancy. The characters of the ulcerations shall 
be stated in the second part of the work, when treating of inflam- 
mation of the mucous membrane of the stomach and bowels. 

[Elaborate investigations into the phenomena of that form of con- 
tinued fever which resembles the typhus of camps, have been made 
by MM. Louis and Chomel; and the joint labours of these two dis- 
tinguished pathologists, have presented to the public a mass of facts 
which greatly enrich the history of this prevalent febrile affection. 
The term typhoid fever is preferred by both these authors, as being 
most applicable to the protean shapes of the disease, and as reconcil- 
ing the conflicting names under which it has hitherto been described. 
Jt has also the advantage of not originating in any preconceived idea, 



[TYPHOID FEVER.] 135 

founded upon groups of symptoms which are merely incidental. 
Typhoid fever, according to the signification which is given to it, 
embraces a wide range, and includes various modifications which 
hitherto have been considered distinct. 

Upon consulting the records of endemic and epidemic fevers which 
have assumed the form of typhus, the minute details of their exterior 
symptoms will be found sufficient to convey accurate ideas of their 
more prominent characteristics; but when we search for information 
as to the extent, the precise nature, and the location of the anatomical 
lesions accompanying them, the descriptions will be found exceed- 
ingly defective. 

The peculiarity of the researches of Louis and Chomel into the 
nature of typhoid fever, consists in drawing the attention of the pro- 
fession to certain symptoms referrible to existing lesions'which had 
not before been regarded as peculiar to this affection. From these 
they deduce a diagnosis established upon the sure basis of nature; 
and, from the certainty which exists of an invariable diseased con- 
dition of particular organs, direct the attention to the consequent 
dangerous results. The prominent and material facts are all that 
we can now present ; but these shall be given as faithfully as the 
occasion will permit. 

The invasion of typhoid fever is not always the same, nor are the 
symptoms invariable. Precursory indications of the attack may 
exist, or they may be wanting, but most commonly the attack is 
sudden. Of 112 cases, 73 were attacked suddenly, and 39 laboured 
under premonitory symptoms. The phenomena of invasion were 
as intense in those who were warned of its approach, as in those 
who were not; viz., intense headache, sometimes preceded by diar- 
rhoea; alteration of the features, stupidity, muscular weakness, ab- 
dominal pains, &c. 

Chomel has divided the march and progress of the disease into 
three period-;, each including seven days, and characterized by par- 
ticular manifestations; these are called septenary periods. 

Symptoms occurring during the first period. — Headache in all 

ility and stupor, diarrhoea, meteorism, increased sensibility 

of the abdomen, especially in the right iliac region, gurgling when 

jure is made upon the lower part of the belly, epis taxis, and 

finally the eruption designated by the name typhoid eruption. 

Daring the first period, the change of countenance is very striking: 

the features .'in- without expression, and evince an indifference and 

apathy which are peculiar, and from which the patient can scarcely 

he roused. In consequence of great weakness, the patient sleeps 

apon his back, and, it forced to sit upright, dizziness and vertigo 

compel him to resume the horizontal state. Insomnia is a frequent 

attendant, partaking of that form of disturbed rest which is called 

'•"mi/ vigil. The mouth becomes sticky, its humidity diminishes, 

the saliva is thick and small in quantity ; this is the first degree of 

dryness, which afterwards becomes complete. The colour of the 

ue is far from being as uniform as is staled, or of as much con- 

>me imagine. It is, at the commencement, red at the 

d ■! edges, with a white film on each side; but for the most pan. 



136 [TYPHOID FEVER.] 

this reddening of the tongue does not present, itself until the termi- 
nation of the first period, and is preceded by a whitish, suburral 
condition. The lips and teeth become dry and incrusted at the same 
time that the mouth is parched. Sore throat is not an unusual symp- 
tom. Loss of appetite, nausea, and vomiting are frequently noticed. 
Great thirst is an usual attendant. 

Diarrhoea is one of the most constant symptoms of this period, ap- 
pearing in nearly every case ; it may, however, be postponed to the 
commencement of the second. It differs as to the number of the 
evacuations, and the character of the matter voided. Meteorism or 
flatulent distension, is owing to the presence of gas in the bowels, and 
in obscure cases can only be detected by percussion ; but at times the 
abdomen rises above the level of the thorax, and considerable unea- 
siness is the consequence. Gurgling noises are owing to the combined 
effect of gas and the liquid contents of the bowels, passing from 
portion to portion, favoured by the peculiar condition of the ileo- 
coecal valve. 

At the commencement the general reaction is high, with well- 
marked inflammatory symptoms, but these in a few days diminish ; 
the pulse retains its frequency, but loses its fulness and force, becoming 
small and weak. The skin is aridly hot, and frequently continues so 
throughout the disease. The heat is in the first instance accompa- 
nied with moisture, but soon becomes dry and mordicant. Epistaxis 
is an important circumstance, and its frequent occurrence is peculiar 
to this affection. The respiration is affected with the sibilant rale; 
there are cough, and expectoration of transparent, viscid, tenacious 
mucus. The last phenomenon we shall mention is the typhoid erup- 
tion. Of 54 cases in 1S31-32, but two presented this symptom as 
early as the sixth day; in the remainder, it was witnessed during the 
second and third periods. Death is rare within this first term; it 
happened once in 42 fatal cases. 

Symptoms of the second period. — At this time we have new 
symptoms submitted to our inspection, and modifications of those 
which already exist. Generally, upon the seventh or ninth day, the 
typhoid eruption makes its appearance. This consists of small, rose- 
coloured spots, from half a line to two lines in diameter, of a rounded 
or oval form, scarcely elevated above the skin, and which are readily 
removed by pressure, but return immediately when it is withdrawn. 
These spots are scattered over the abdomen, sometimes upon the 
chest, and rarely upon the thighs, arms and other parts. To cha- 
racterize typhoid fever, the number of them should at least amount 
to five-and-twenty. Their continuance is by no means uniform, dis- 
appearing in two or three days, or remaining twelve or fifteen. 
When they are about to disappear, their colour becomes less intense, 
and finally fades away entirely. No conical form or vesicular con- 
dition is ever apparent. Of 70 cases, 16 were without them. The 
time of appearance may, however, be late in the progress of the 
disease, and it has even been observed as late as the 39th day. 

Another eruption is witnessed during this period, characterized by 
the form of vesicles called sndamina. They are minute, elevated 
and transparent, and can be more readily perceived upon viewing 



[TYPHOID FEVER.] ]37 

them obliquely, and although not exclusively confined to typhoid 
fever, they, for the most part, appear twice in the progress of the 
disease, first at its commencement, and again towards its termination. 
There exists a remarkable disposition to the formation of sloughs, 
and the production of foul sores upon different portions of the body, 
especially where pressure is kept up, or irritating substances have 
been applied. Ulceration, however, is not confined to the external 
parts, but is observed in the mouth, throat, and on the tongue and lips. 
Leech bites and minute incisions, may exhibit the same tendency to 
ulceration, but this circumstance is rare. It is at this time that pre- 
vious stupor and prostration become more marked, occasioning perfect 
helplessness, and involuntary discharges from the bladder and bowels. 
Finally, difficulty of deglutition, consequent upon organic lesions of 
the throat, or upon weakness; spasmodic action of the muscles of the 
face and extremities, or complete rigidity of them ; delirium; in- 
crease of meteorism and diarrhoea ; bloody alvine discharges, together 
with great fetor of the perspiration and pulmonary exhalations, are 
the most essential symptoms of this second period. 

Symptoms of the third period. — The phenomena of this period 
vary according to the change which may be undergone, whether to 
a safe state of convalescence, or to a still more alarming condition, 
shortly terminating in death. If the former event is about to hap- 
pen, all the symptoms are gradually ameliorated. But should the 
contrary termination threaten, symptoms indicating the near approach 
of dissolution will be apparent. The stupor becomes profound; the 
mouth secretes a grayish, sanious, fetid discharge. The urine has an 
unnatural, disagreeable smell. Respiration is more and more cmbar- 
ed; the pulse is small, weak, and fluttering; the skin becomes 
cold and clammy, and the countenance has that peculiar expression 
which is designated fades hippocralica. In this condition the patient 
dies, or convulsions may precede the concluding scene. 

( I rty-two cases which terminated fatally, ten died during the 
two former periods; the remainder, after the third had been entered. 

Anatomical lesions. — There are peculiar organic changes so con- 

■ ;.- attendant on this disease, thai an exception rarely occurs; 

but there are others, found in different organs, which arc not so in- 

. -ml which may be regarded as accidental. The anatomical 

i y, therefore, be separated into two classes, constant and 

nstant. Tin: first occupies the mucous follicles of the intestines 

and ibt: mesenteric ganglia. 'Inn follicles are of two kinds, isolated 

and clustered j and their mode of alteration and appearance is by no 

(rieana lb'' same under all circumstances, but varies according to the 

period >>\' the disease and the form which it may assume. It is a 

cult maitcr to determine when alteration of the follicles com- 

''.'■lib never happens prior to the seventh day. Of .""» 

ispecled by M Louis, the earliest period at which death 

was the 8th day. When under these circumstances an 

mid.- into the abdomen, the intestines are noticed dis- 

ten li i , which augments their transparency, and permits us 

to distinguish exteriorly numerous opaque spots corresponding to 

the diseased follicles. Examining into the nature of the change in 

12* 



138 [TYPHOID FEVER.] 

the latter, they will be found prominent and swollen, and from having 
their edges brought into relief, present somewhat the form- of mush- 
rooms. Their colour varies in intensity, but is always more or less 
marked, exceeding the redness of the surrounding mucous coat. 
Their size and form retain as little uniformity as their colour: the 
largest are elliptical, exceeding, in rare instances, two or three inches 
in length, and half or a whole inch in breadth ; these occupy the 
glands of Peyer. The smaller ones are round, and have their seat 
in the same glands; but besides these there exist isolated and scat- 
tered prominent follicles, rounded and swollen ; the latter are the 
glands of Brunner. The usual location of these appearances is upon 
the side of the intestine, opposite the mesenteric attachment, and they 
are more numerous, denser and larger near the valve. The plates 
(placques) give to the feel a sensation as if a solid, elastic substance 
was introduced between the intestinal tunics. Upon the seventh 
day, in a single case, and at periods not long after in other cases, the 
mucous membrane covering them had undergone no appreciable 
change; if any thing, its thickness was rather diminished than in- 
creased. If these enlarged glands are cut into perpendicularly, the 
mucous membrane is first divided; then a layer of yellowish-white 
matter, homogeneous in consistence, firm and brittle, the cut surfaces 
being smooth and shining: the thickness of this matter varies from 
one to two lines, and beneath is found the cellular tunic. An orifice 
is rarely noticed in the clustered follicles, but is readily detected in 
the isolated. 

At this stage the mesenteric ganglia, situated between the lamina 
of this attachment, which are nearest to the diseased follicles, are 
increased in size and become red. They are even observed as large 
as a pigeon's egg. There is sometimes complete softening, while 
at others their firmness is rendered greater. These are the most im- 
portant lesions, but in their development an uniform state of pro- 
gression is observed. Ordinarily those nearest the ileo-coecal valve 
are the first to become affected : and, in the early stages, as they 
recede from this focus, a greater degree of healthiness is noticed: but, 
as the disease advances, a greater number become affected. The 
same circumstance holds both with regard to the follicles and the 
ganglia. Sometimes several feet of intestine are implicated in this 
manner. Later in the disease, other conditions are perceived : the 
mucous membrane investing the follicles becomes rugose, hollowed 
out, and disappears entirely, leaving an excavation which pene- 
trates more or less deeply into the subjacent layer; but as this lat- 
ter is not entirely removed, there remains a portion of the gland to 
show the progress of the alteration. According to the combined ob- 
servations of Louis and Chomel, it was determined that ulceration 
commences from the eighth to the fifteenth day. Ulceration pursues 
the same course as tumefaction; beginning at the same place, and 
being more frequently observed in the glands of Peyer. The aspect 
of the ulceration presents two varieties: in one, it commences in the 
mucous membrane, originating at a minute point and extending until 
the whole gland is involved: in the other the ulceration begins with 
softening of the yellowish matter, and a process is gone through re- 



[TYPHOID FEVER.] 139 

sembling gangrene, by which the whole substance is removed : the 
remains are evident by inspection, but diminished by suppuration, 
while the investing mucous coat is in a comparatively healthy con- 
dition, or only partially displaced. This latter variety is more fre- 
quently met with in the clustered follicles. Fully formed ulcers 
assume conditions which it is important to notice: their edge or bot- 
tom presents no remains of the substance of the follicle in a partially 
broken down state ; it has entirely disappeared, leaving a vacuity in 
the mucous membrane. The form of the ulcers is various : some 
being elliptic, others round : they are also equally dissimilar in size ; 
and in some cases the borders are so smooth as to convey the idea 
of their being made by a punch. In some, the mucous membrane 
alone lias been removed, the bottom of the ulcer consisting of cellular 
tissue; but in others the cellular and muscular layers of the intestine 
are likewise deficient, the exterior peritoneal coat preventing com- 
plete perforation. During the first and second periods, it is rare that 
the ulcers are as numerous as the prominent follicles. 

Opportunities are sometimes afforded of witnessing the mode in 
which these ulcers heal. It is precisely the same mode that ulcera- 
tion of the skin undergoes in the process of cure : minute granulations 
sprout up, and are converted into the reticulated tissue, which forms 
a true cicatrix. Cicatrization, after it has been completed, is plainly 
demonstrable; but after a length of time it becomes confounded with 
the untouched mucous structure, and no trace of it is to be detected. 
Corresponding to the advanced change in the follicles, is a condition 
of the ganglia closely allied to suppuration, and in some cases pus is 
found in their substance. 

Lesions of organs, inconstant as to their presence or absence, appear 
at times as accidental accompaniments of the pathological conditions 
which have been somewhat minutely described. They are, ulcera- 
tion of the mouth, tongue, pharynx and oesophagus — injection, soft- 
ening, alteration of the relative thickness of the mucous coat of the 
ttomach, very rarely ulceration: similar changes occur in the intes- 
tines; alteration ol the Bize, consistence and colour of the spleen; and 
leutly of the liver: varied conditions of the pulmonary ap- 
paratus are occasionally present, for the most part the consequences 
of inflammation. And lastly, lesions of the brain and its appendages.* 
. words with regard to the diagnosis, the nature of the affec- 
tion, ami one or two interesting facts connected with the peculiar 
anatomical lesions, will conclude this very brief account of the re- 
>hes of Louis and Chomel. At the immediate onset of the dis- 
ease, it is extremely difficult to determine the character which will be 
imed, and BOme time mU8t elapse before the precise symptoms 

• [The preceding remai la on the morbid conditions of the gastro-intestinal mucous 

irane, are republished villi little variation from '>ur first edition. Nothing of 

the kiml w.i^ embraced in the f/rti London edition; bol in the Uut, some of these 

farts arei i lapter on iii>- " Inflammatory a Sections 

lined within the cavity of ihe abdomen.'' As I have con idered 

these lesions in tlirir rel r, and .is the author, on ili«' other hand, has 

I them chiefly in >■ i Inflammation, I have thought it better to let 

ly.thac atti mpi to combine them in a single chapter. 

I iap. VII of Ike prestnt volumr | 



140 [TYPHOID FEVER.] 

enable us to form an accurate opinion. Nevertheless, even during 
the first few days, a pretty correct conjecture may be drawn from 
the occurrence of several attendant circumstances. Thus, if the attack 
be sudden — if, from the first, persistent headache be established, with 
giddiness and tottering in the gait, combined with well-developed 
fever, suspicion will be awakened; but if, still further, upon the second 
or third day, there exist diarrhoea, prostration, commencing stupor 
and nasal haemorrhage, this suspicion will be almost converted into 
certainty. But it is most prudent to suspend our decision until more 
fully determined symptoms appear; and these are meteorism, typhoid 
or rosaceous eruptions, low muttering delirium, sudamina, fuliginous 
aspect of the mucous opening, &c; which remove all doubt and ob- 
scurity. 

A question presents itself, how far the disease termed typhoid fever 
is connected with the lesions which have been described. To deter- 
mine this, we must recur to the division which was made of the 
anatomical derangements into two classes, constant and occasional. 
Now it being conceded that the latter are but accidental, important 
truly as complications, but not necessary to the existence of the dis- 
ease, the constant lesions will constitute the objects of our inquiry. 
Are they so uniformly present in all cases as to warrant the appella- 
tion constant? In all but a very few rare instances they have been 
found. These instances have occurred in the hands of such able 
observers as Andral and Louis; and it may still be regarded as un- 
decided whether they were true forms of typhoid fever, or depending 
upon circumstances which were wholly independent of it. As to the 
secondary or primary nature of the lesions, a great deal could be said. 
The intensity of the symptoms, however, bears no proportion to the 
number of diseased follicles, inasmuch as numerous cases occur in 
which these are deranged but to a small extent : in two cases, but a 
single ulcer could be detected. M. Chomel is inclined to the idea 
that in this respect the affection is allied to the exanthemata. 

A remarkable termination sometimes happens in this affection: it 
is the sudden and unexpected occurrence of peritonitis, which fre- 
quently succeeds the exhibition of cathartics: the cause of its produc- 
tion is dependent upon intestinal perforation, and consequent escape 
of the liquid contents of the bowels into the abdominal cavity; an 
event which is almost necessarily fatal. 

Critical days. — There are certain changes, as the author has 
already observed, (page 67,) which occur in most forms of remittent 
and continued fever, such for example, as the increased exacerbation 
on the alternate day, the increase of the febrile symptoms, once or 
twice in each day, and lastly, there seems to be a law of nature by 
which fevers tend to a termination on certain days in preference to 
others. This doctrine, which originated with Hippocrates, was denied 
by Celsus, and is still the subject of great diversity of opinion. It is 
remarkable, however, that De Haen has put Hippocrates to the test 
on his own data ; for on analyzing all the cases of fever recorded by 
the "father of medicine," he finds the doctrine of critical days to be 
sustained by the results; for of 168 terminations of fever, 107, or 
more than two-thirds, took place on the critical days. The latter 



HECTIC FEVER. 



141 



are the third, fifth, seventh, ninth, eleventh, fourteenth, seventeenth 
and twentieth; and the fourth and sixth have always been regarded 
as frequently but secondarily critical. 

I think it will be admitted by most practitioners who have given 
attention to this question, that when we can unequivocally establish 
the day on which fever commences, the disease will, in the great ma- 
jority of cases, be found to terminate on some one of the assumed 
critical days. "The following table," observes Dr. Tweedie, "con- 
structed from 630 cases where the commencement and termination 
of the fever could be fixed with tolerable precision, certainly presents 
a remarkable correspondence with the ancient doctrine. 



DA VS. 


DAYS. 


Critical 


Non Critical 


Cases. 


Critical 


Non Critical 


Cases. 


3 




G 


U 




G3 


1- 


4* 


18 




15 


10 


5 




80 




16 


11 


.;• 


6* 


34 


17 




34 


7 




129 




18 


2 




8 


2G 




19 


4 


9 




80 


20 









10 


17 




21 


15 


11 




69 




22 


3 




is 


80 




23 







..; 


15 









Dr. Tweedie further remarks that of these 690 cases, (which 
occurred under the observation of Dr. Welsh, in the Edinburgh epi- 
demic of 1819,) the crisis took place in 470 on critical days; in 52 
instances on the subsidiary critical days, and in but 108 cases on the 
non-critical days; and he adds, that these data are founded on the 
lever il types of remittent or continued fever, at a time when syno- 
cha and synochus were prevalent diseases.*] 



HECTIC FEVER. 

I hi tic fever is generally supposed to be symptomatic; even Cul- 
len embraces this opinion. It may be defined to be febrile symp- 
toms, occui ring in the ruins.: of some, internal chronic disease, when 
ili<- patient is much debilitated. Heberden states that irritation in 
:i will jive rise to it. An opinion has been pretty 
general, that hectic fever is produced by no other cause than the 
lion of pus; and when pus was not found upon dissection, it 
was hastily concluded thai it had existed* bul was all absorbed; or 
that hi metimes idiopathic. My <>wn belief is, that 



- ..,, ,,,.■• pa l hie. My own belief is, that 

mbination of symptoms has no necessary connection whatever 
with put; and according to my experience, it most frequently (al- 

• !.:■■. f Pi :■■ ilea! Medicine, Vol. I p. 1 13.] 



142 [HECTIC FEVER.] 

though certainly not always) depends on inflammation of the mucous 
membranes, and more particularly that of the stomach and bowels. 

Symptoms. — Hectic fever is attended with great and increasing 
debility; a weak quick pulse; each paroxysm commences with 
chilliness, succeeded by reaction, which is soon followed by copious 
perspiration. Indeed, sweating is at all times easily excited by any 
exertion. The surface is pale, except the cheeks, which present 
what is very aptly styled the <•' hectic blush;" and there is frequently 
great wasting of the muscles. The appetite is impaired, the stomach 
occasionally very irritable, and in nine fatal cases out of ten, diarrhoea 
comes on during the course of the disease. The discharge from the 
bowels is always very fetid. The breathing is anxious. The patient 
is generally restless, and frequently complains of pains that are 
ascribed to rheumatism. 

[It is, however, remarkable, that with all the general disturbance 
of the functions, the tongue is often perfectly clean to the last, the 
appetite good, and the digestion seemingly unimpaired. In many 
instances, moreover, I have observed the absence of headache or 
any cerebral excitement or distress, even during the height of the 
febrile paroxysm. The latter usually comes on in the afternoon or 
early in the evening, and continues through the night; but towards 
morning it passes off with colliquative perspiration, leaving the 
patient in an exhausted condition, both of mind and body. Beside 
this principal paroxysm of fever, there is often a second and milder 
one in the morning, which runs its course more rapidly, and is less 
depressing in its effects. 

The period between the paroxysms is almost invariably a mere 
remission and not an intermission of fever, and the pulse continues 
at ninety or upwards, abating in force, but not much in frequency. 

The advanced stage of hectic fever is often marked by ulcerated 
throat, an aphthous state of the mouth, with a remarkable trans- 
parency of the citeguments, and a preternatural brightness of the 
eyes.] 

It is said that this disease is liable to be confounded with intermit- 
tent fever; but the history of the case, and the appearance of the 
patient, will readily distinguish them. 

Treatment. — As hectic fever depends upon a morbid condition of 
some structure of the body, our attention must be directed to the seat 
of the disease. Surgeons very often cure patients of hectic fever, by 
cutting off a diseased limb which had produced the constitutional 
symptoms. There is no case in which the difference is so strikingly 
shown between routine practice, and that which is directed by sound 
pathological views. The routine practitioner will be invariably 
found to treat some of the symptoms thus: — Has the patient no 
appetite ? Give him a tonic. — Is he purged ? Prescribe an astring- 
ent. — Is he griped? Give him an opiate. — Is the urine scanty? 
He must have a diuretic. — Has he profuse perspirations? Let acid 
drops be exhibited."* 

[* Yet it muslin candour be confessed, that there are numerous modifications of 
disease in which we can do little else than palliate symptoms. Thus, every practi- 
tioner must have met with examples in which life has' been prolonged and suffering 



GENERAL PATHOLOGY OF ERUPTIVE FEVERS. 143 

A pathologist, it must be admitted, is often obliged, in the present 
state of our knowledge, to act empirically; but his remedies will 
always be found to be few in number. If the patient have diarrhoea, 
he will endeavour to ascertain upon what morbid state that symptom 
depends ; if there be pain in the abdomen previous to an evacuation, 
if the pain be increased by taking a cold drink, if the tongue be red 
and glazed, if there be aphthous ulcers in the mouth and throat, if 
the stools are mixed with mucus, or are watery and fetid, he knows 
he has to treat inflammation, and probably ulceration of the intes- 
tines. This leads him to apply a few leeches to the abdomen, if the 
patient's strength be not greatly reduced, followed by contra-irrita- 
tion ; and then, if there be any remedy that he knows will relieve 
the patient, that remedy he will prescribe. It is truly lamentable 
to see the symptomatica! physician, one day treating the diarrhoea 
with astringents, and the next waging war against the perspirations. 
— This subject will be more fully illustrated hereafter. Opiates are 
frequently of considerable use in soothing the patient's sufferings. 



GENERAL PATHOLOGY OF ERUPTIVE FEVERS. 

The diseases, which fall to be described under this head, are to 
he considered as fevers, attended during part of their course by 
eruptions. Whatever difference there may be in the appearance and 
form of the eruption, they have a certain general character common 
to all, viz., thai febrile symptoms precede the eruption. 

According to the hnnionral pathology, the fever is produced by a 
concoction of the humours, by which a peccant matter is thrown to 
tin' Burface, forming the eruption. Other pathologists look upon these 
.1- peculiar and essential affections of the epidermis, some- 
i\mes followed by inflammation of the chest and its accompanying 
fever; ami they account for the sore throat which occasionally 
occurs, by its continuity between the skin and the diseased internal 
organ. 

vn opinion is, that the eruption ought to be regarded as a 
. inpioni .if this class of diseases. Yet it cannot be denied 
that there is something very peculiar in it — peculiar inasmuch as the 
eruptions present external characters, differing from each other, as 
well as from other eruptions, and that the diseases occur only once 
m ;i lifetime. After a ion- and patient investigation, comparing the 
symptoms with the appearances found on dissection, I have come to 

the opinion thai the mucous ineinliranes are the seal of the disease, 

■ue of which 1^ inflammation, more or less acute and exten- 
sive j and that the put generally most implicated, is the mucous 

membrane Of Ihe Inn-' . particularly in measles and small-pox ; while 

b colliquative pentpiraiion, in- drool and 
called empil Tlicse observations will be practically 

I ...hlM.s.] 



144 GENERAL PATHOLOGY OF 

that of the bowels is the part chiefly, if not principally, affected in 
urticaria, roseola, and military fever.* The eruption is merely to be 
regarded as a symptom, and by no means a universal symptom. 
It is well known that many cases of eruptive fevers are very mild, 
and require lit tie treatment, while others are extremely severe and 
fatal; and that a great deal depends upon the eruption, whether it 
comes out at the usual period, and whether it remains out, or pre- 
maturely and suddenly recedes. The eruption, in point of fact, ought 
to be regarded as a natural blister, acting as a contra-irritant. It is 
produced by powers inherent in the constitution, that enable it to 
remove so much of the diseased action from an internal organ, the 
functions of which are more immediately necessary to life. In slight 
cases, I conceive the eruption is in proportion to, if it does not exceed, 
the amount of the internal disease. Tins may be stated without 
reference to the quantity of the eruption, except, perhaps, in small- 
pox. There can be no doubt that the eruptions are produced by in- 
flammation of the cutis, which consequently must take off so much 
of the determination of blood, and so much of the diseased action 
from internal organs. 

These circumstances, it appears to me, are clearly proved — 

1. By attending to the constitutional commotion and oppression 
of the whole system, and the morbid changes in the functions of 
various organs, for many days before the appearance of the eruption. 

2. By the relief afforded, in general, after the free development of 
the eruption. 

3. By the increased suffering and danger which exist when the 
eruption is deficient, or when its repulsion suddenly and prematurely 
takes place. 

4. By the relief which follows proper treatment; and, 

5. By the appearances observed on dissection. 

With respect to the first of these points, it may be stated, that the 
eruption does not appear in general till the third, fourth, or fifth day 
of the complaint, and during that time, the patient labours under the 
combination of symptoms denominated fever, and sutlers from the 
impeded functions of all the organs ; all the symptoms denote internal 
disease. That the respiratory organs suffer very considerably may 
be discovered by the state of the respiration, the cough, the anxiety 
and colour of the countenance, but more particularly by auscultation, 
which will announce bronchitis in its first stage. In this stage, 
which is called the eruptive, there are frequently affections of the 
brain announced by the patient suffering from delirium, lethargy, 
or even coma; and it is by no means uncommon to see convulsions, 
or other serious nervous symptoms, come on, at the period when the 
eruption ought to have been fully developed, but has not yet ap- 
peared, or has only partially come out. 

As to the second point, which has been offered in proof, it is to be 
observed, that the symptomatical physician will not be inclined to 

♦ ["Measles and scarlatina begin by gastro-enteritis, and by an acute catarrhal 
inflammation of the eyes, nose, throat, or bronchia?. These phlegmasia? constitute 
the whole danger of these diseases, by becoming violent, and attacking the brain 
and all the viscera. — Eroussais.] 



ERUPTIVE FEVERS. 145 

receive it as evidence in favour of the views which I wish to estab- 
lish. He will say there is no relief; and in so far he will say truly. 
The eruption being occasioned by extensive inflammation of the skin, 
produces great irritation, and very often an increase of the febrile 
symptoms; that is to say, the person will complain more of thirst, 
restlessness and uneasiness, than previously. But still a pathological 
eye will discover relief — relief produced by the translation of a part, 
and perhaps a great part, of the diseased action from internal organs 
to the surface. The symptomatica! physician will point out to us 
that the respiration is still hurried and short, but we may be able, 
after an examination of the lungs, to assure him that there is less 
congestion of the lungs, and less inflammatory action in their mucous 
membrane, than before; and that the state of the respiration which 
he has noticed, is now produced principally by the hurried circula- 
tion through the lungs; so that, pathologically speaking, the patient 
is relieved. A common blister, when it is sufficiently large, very 
frequently increases the patient's sufferings, while it has mitigated 
the disease. 

The third point of proof is the acknowledged danger which exists 
When the eruption is deficient, or when its repulsion has taken place. 
Dr. Gregory, in his lectures, when treating of scarlatina, used to 
make the following statement: "We find a connection similar to 
that between the efflorescence and other symptoms in this disease, 
existing between the eruption and general affection in measles; for 
there it is not critical, but is accompanied with an alleviation of the 
symptoms, which ,js greater or less according to the degree of the 
eruption; and all the symptoms are very much aggravated by the 
repulsion of it." Indeed, if the reader will refer to any author who 
has written upon this subject, he will find, that in the severe forms 
of the disease, which are commonly described under the terms scur- 
latina maligna^ scarlatina anginosa, and in rubeola putrida also, 
the em pt ion is cither wanting, or it appears at irregular periods, but 
is seldom permanent; and it is in these severe cases that we meet 
with what arc called typhoid symptoms, diarrhoea, and haemorrhage 
from the nose, mouth, or bowels. The first question which it is 
natural fur an inquirer to ask, is, by what cause is the danger pro- 
duced ? It appears to me, that the reply is very easily made. There 
has been lately en extensive inflammatory action in the skin, which 
required a determination of blood to support it. During this time 
the Bymptoms were not very severe; but the moment that the blood 
■ >k the surface, it was marked by increased internal distress; the 
: ition became more laborious, and the patient more or less 
comatose; perhaps convulsions appeared. Is it not quite natural, 
therefore, lo conclude that these effects are produced by the sudden 
determination of blood taking place towards internal parts, produc- 
ing engorgements, and ending in inflammation of one or more organs, 
it" the eruption be nol speedily brought hack? Bui it will frequently 
that kind of inflammation winch has been described as sup- 
d, and which cannot fully develop itself. The external symp- 
toms will lead a symptomatica! physician to stimulate and give tomes, 
When the pathologist would try the effect Of the warm bath, stiniu- 
13 



146 GENERAL PATHOLOGY OF 

lating frictions, and bleeding by leeches, if he could not open a vein; 
and he would also apply blisters. 

The fourth point in the evidence, is the relief afforded by proper 
treatment. When the eruption is repelled from the surface, we use 
all the means within our power to recall it : the warm bath and 
stimulating frictions are first employed. The warm bath, which is 
the principal means to be depended on, may not be at hand, or we 
may have tried these remedies and failed ; but we ought not to delay 
long under any circumstance, to open a vein, if the eruption be not 
speedily re-produced, particularly if the patient be above two years 
of age, and a vein can be found ; if not, we must depend upon 
leeches, warm bath, and blisters. By opening a vein, however, we 
prevent a great deal of mischief and risk to the patient. If we cannot 
recall the blood to the surface, we reduce the quantity of it in the 
whole system, and thereby remove the accumulation from internal 
organs, alter the determination of blood, and then assist the system in 
creating reaction, if necessary, by the addition of a stimulant. But 
all this, to produce benefit, must be done instantly ; every moment 
lost, diminishes the chance of relief. I am entitled to speak strongly, 
from the great success which has attended the treatment here recom- 
mended, not only in my own practice, but also in that of many of 
my pupils. Although many of these cases might be quoted in detail, 
yet the perusal of the following case, translated from the Clinique 
Medicale, by M. Andral, vol. iii. p. 72, will perhaps make a sufficient 
impression upon the minds of my readers. The case is entitled, 
"Jlcute bronchitis; Measles; Premature disappearance of the erup- 
tion; Fatal dyspnoea" 

"A baker, set. 20, of a strong constitution, was affected within the 
last five or six weeks with slight diarrhoea ; presented on the 10th 
April, all the precursory symptoms of measles, redness of eyes, flow 
of tears, coryza, hoarseness, cough ; and continued in this state for 
the three following days. On the 14th, the eruption appeared, and 
the patient took to his bed. On the 15th, his whole body was co- 
vered, and in the evening he was admitted into the Charite ; when 
he had a confluent, well-marked eruption ; hardness and quickness 
of the pulse; redness of the tongue and lips; and a strong cough; 
there was otherwise no alarming symptom. Towards the middle of 
the night, the patient experienced, all of a sudden, an oppression, 
which rapidly increased, and on the following morning we found 
him in a state of partial asphyxia ; the eyes prominent ; the face of 
a violet colour; respiration short and very frequent; cough nearly 
constant ; little mucous expectoration. Percussion elicited the natural 
sound through the whole of the chest, but the mucous rattle was 
audible, in different points, by means of the stethoscope. There re- 
mained only a few pale spots of the cutaneous eruption, which were 
fast dying away. The pulse preserved its frequency and hardness, 
and the tongue its redness. This train of symptoms seemed to indi- 
cate the existence of pneumonia; nevertheless, the pathognomic signs 
of this complaint were completely wanting. 

"Could a simple bronchitis occasion, by its extreme acuteness or 
sudden exasperation, so much dyspnoea ? and might hot this inflam- 



ERUPTIVE FEVERS. 147 

mation, joined to that of the alimentary canal, account for the com- 
plaint with which the patient had been so violently attacked? Be 
this as it may, the indications of treatment were clear ; — to lessen 
the internal inflammation,* and to effect a return of that on the 
skin. With this object, twenty leeches were applied to each side of 
the chest, and ten to the epigastrium. After the blood had ceased 
flowing, a blister was applied to each leg, and the skin rubbed all 
over with liniment of ammonia. Marked relief followed the use of 
these means; in the evening the respiration was much less impeded, 
the cough less frequent, and the tongue had lost its redness. The 
eruption, however, had not returned. 

" 1 1th, The patient presented the symptoms of a severe bronchitis, 
accompanied with fever ; the respiration was only slightly accele- 
rated. 

■ ISM, The fever was reduced to almost nothing, and the opaque 
expectoration announced the speedy termination of the bronchitis. 
In the evening, the respiration suddenly became very difficult, and 
twelve ounces of bloodt were abstracted from the arm. The next 
morning the dyspnoea was still very considerable, and the pulse had 
become more quick. Two blisters to the thighs. During the whole 
of the day, the sense of suffocation continued to increase. 

" 20///, Face extremely livid, violent colour of the lips, orthopnoea ; 
from the appearance of the patient, one would have thought that he 
was dying of aneurism of the heart. 

" Inspectio cadaver is. — The mucous membrane of the larynx, 

trachea, and bronchial tubes, and of the smaller ramifications, were 

of a scarlet red. In a few points at the beginning of the division of 

the bronchia, there were some white concretions, resembling the 

membrane found in croup. 

"The lungs were sound and crepitated throughout their whole 
nt; posteriorly they were gorged with blood. Heart natural ; 
clots of blood of a deep black in the right cavities; stomach white, 
as well as tin- smaller intestines, which contained a great number of 
ascarides and lumbrici in the lower portion ; the caecum contained 
ral worms, (tricocephales); its mucous membrane presented a 
pot near the valve, from which arose three or four small conical 
• tti'wis. three or four lines long. The rest of the large intestine 
white, and filled with liquid fieces. Liver gorged with blood. Spleen 
large and firm. A great quantity of serum infiltrated into the sub- 
arachnoid cellular tissue ; the cerebral substance was not at all in- 
ral ventricles, especially the right, were distended by 
much limpid serum." 

The fifth point of evidence rests upon the appearances found on 

ction ; and it may he shortly mentioned here, that these consist 

kinds (.f lesions of the brain and membranes, usually produced 

by acute and subacute inflammation. The same observation may 

the distinguished author treed (he term " congestion* 1 instead of inflamma- 

ad had !>•• employed venesection without dels ies, lie 

1 altered the determination of blood, ana probably relieved the diseased 

1 ought i«> have been bis praci , from the hardness «'i the pulse. 

♦ I' etted ihai this was not done two days earlier. 



148 SCARLET FEVER. 

be made respecting the organs in the thorax. Within the abdomen, 
the chief diseased appearance to be observed is in the mucous mem- 
brane, particularly of the large intestine, which is inflamed, some- 
times ulcerated. But in no case does the pulmonary system escape. 
The appearances in the brain and abdomen are not so universal, and 
may occasionally depend upon the impeded functions of the lungs, 
as will be shown hereafter. 

If these observations be not fallacious, bleeding to a sufficient 
extent ought not only to relieve the constitutional symptoms during 
the eruptive fever, but after the eruption has appeared, ought to 
destroy it. Observations and experiments frequently performed and 
repeated by myself, and by my pupils, enable me to state, that these 
are facts which I shall not be afraid to repeat before the highest 
authorities in the profession, and stake my professional reputation 
upon the general result of the plan; having already seen recoveries 
take place, under this treatment, in cases in which such a happy 
termination was scarcely to be anticipated. It also follows, if these 
things be true, that even in ordinary cases there are two periods more 
critical and dangerous to the patient than any other ; these are, the 
period at which the eruption ought to make its appearance, and that 
at which it should naturally disappear. In the first case, the internal 
disease has gradually become extensive and severe, and wants relief 
by means of the eruption. In the second, the disease which had 
existed at first, having been relieved by the external irritation, is 
now in danger of being reproduced by its cessation; and this of all 
others is the period at which, in the slightest form of the disease, the 
patient stands most in need of care and vigilant attention to the con- 
dition of internal organs. 

This pathological description, if it should appear deficient, is so 
only, I am convinced, from the want of sufficient illustration, which 
would require a separate treatise on the subject. It is introduced in 
this place to prevent repetition, when treating of each of the diseases 
which fall now to be described. 



SCARLET FEV T ER. — Scarlatina. 

This term is employed to denote a disease attended by a fever, 
sore throat, and a red rash on the surface ; which rash appears some- 
lime between the second and fifth or sixth days of the disease, first 
upon the face and neck, and progressively spreads over the body, 
terminating between the seventh and tenth days. The rash has 
very much the appearance of the shell of a boiled lobster, and fre- 
quently there are minute* vesicles. The inflammation of the throat 
sometimes runs into ulceration and sloughing. 

The literary history of this, or of any other disease, is of little im- 
portance in comparison to an intimate acquaintance with its patho- 
logy, and proper means of treatment. Therefore, I shall proceed to 



SCARLET FEVER. 149 

describe the phenomena, without caring from whence the disease 
came, or in what century it first appeared, further than to notice that 
scarlatina and measles were formerly confounded, from their mutual 
pathological resemblance. Sydenham appears to have been the first 
who gave this disease the name of scarlet fever, as well as a distinct 
description of the affection, pointing out the circumstances, with suf- 
ficient precision, in which it differs from measles.* 

The term scarlatina, notwithstanding the philippic of Dr. Mason 
Good, is quite as good as his term Rosalia; it affords us an example 
of what is by no means rare, a disease receiving its name from a single 
symptom. 

Scarlatina has been divided into three species, viz. 

Scarlatina simplex. 

anginosa. 

maligna ; which last includes the disease termed cynan- 

che maligna. My chief objection to these terms is, that they do not 
spring from pathological considerations; and it may be said in the lan- 
guage of Dr. Hamilton, sen., that " it is altogether foreign to my pur- 
pose to engage in this controversy ; and more so, as the distinction 
U'lmiis to lose ground as our knowledge of the disease becomes more 
comprehensive and accurate. The time may not be far distant, when 
scarlatina will be received as the generic disease, the full history of 
which will include the more aggravated symptoms as they appear in 
scarlatina anginosa, and in cynanche maligna; in the same manner 
as the history of variola comprehends the varieties of the distinct and 
confluent small-pox." 

irlet fever is a fatal disease. The plague is scarcely more" 
dreaded at Constantinople than scarlet fever is in Edinburgh ; not 
because the disease is peculiarly severe, but that the notions taught 
in a dark age still prevail, and that certain individuals have not kept 
up their knowledge with the improvements since made in pathology. 

Symptoms, — In eruptive,, as well as other fevers, there are two 
gnat varieties, which may be named the congestive and the infiam- 
mit'iiy; anil subdivisions might be made of different combinations 
two. 

In the congestive form of scarlatina, the patient complains of op- 

"ii, and so much debility, that he cannot support himself. 

more or less severe accompany or precede these symptoms. 

Tli'' lieu is pale, the features sharp, the eyes hollow, and deprived of 

their accustomed animation; the surface cool, particularly the ex- 

Uemilies, while perhaps considerable heat is felt on the trunk of the 

body; the breathing is performed with more or less difficulty; the 

varies, being sometimes soft, and perhaps weak, although it is 

ionally strong; the tongue has a whitish and shrunk appearance. 

If the patient utter complaint, it will be of universal prostration and 

of headache, or weight on the top of the head, together with oppres- 

M the pnecordia, and difficulty in swallowing. On examining 

•jA D I' 1/ : 'Hi run /I '»< mteaj by Dr. Richard Morton and 

ui by Hoffmann. The peculiar characteristics of scarlet fever as di 
in i pointed out by Dr, Withering, toward! 
: Uie last century] 

13* 



150 [SCARLET FEVER] 

the fauces, the parts may appear somewhat swollen, and of a dark 
colour; and should there be any ulceration, it will, perhaps, be 
ash-coloured, and look indolent. It may be stated, and with some 
plausibility, by that class of practitioners who are led only by symp- 
toms, that those just described do not denote tlie existence of 
scarlatina; to which it may be replied, that one individual of a family 
will display such symptoms, while others are labouring under the 
disease in the ordinary form. Similar appearances have also come 
on in the course of scarlatina, upon the sudden disappearance of the 
rash, and further, the cessation of the congestive symptoms has been 
witnessed upon the reproduction of the rash; which phenomena have 
occurred so often, that I am compelled to receive them as part of the 
medical evidence. I have had one opportunity only of examining 
the body after death, in a subject who fell a victim to this form of the 
complaint. The throat was found to be very slightly ulcerated. 
There was considerable distension of the veins in the abdomen, the 
lungs were much congested, and the vessels of the head were re- 
markably full of dark-coloured blood. 

[It is the congestive form of scarlatina which is most usually at- 
tended by convulsions, which constitute one of its most alarming 
complications. These are generally preceded by coma; but the lat- 
ter sometimes continues until death, without any spasmodic action. 
When the convulsions are sudden, however, they are even less to be 
feared than those spasmodic affections of the extremities which come 
on insidiously, indicating a lurking affection of the brain, and always 
giving just cause of apprehension. They are usually preceded by 
some thickness of the voice and spasmodic flexion of the fingers or 
toes ; and these symptoms may last for days, when they become 
general and end in paralysis, coma and death. 

The most malignant varieties of scarlet fever in the United States 
are often wholly unaccompanied by the characteristic eruption. 
They commence with vomiting, followed speedily by purging, and 
both symptoms are often from the first intractable. The skin as- 
sumes a livid, cadaverous hue, the features shrink, the surface is cold, 
and the patient dies within ten or twenty-four hours, in a state of 
restless and muttering delirium. 

Another very dangerous complication is that of croup, from which 
I have witnessed but a single recovery. Yet it is also to be observed 
that these forms of scarlet fever which are mild in their accession, 
often become slowly but progressively intractable, pervafling the 
whole system like an insidious poison, impairing the function of every 
organ, and finally exhausting the patient between the fifteenth and 
thirtieth day from the commencement of the disease. 

Scarlatina is proverbially a disease of infancy and childhood, and 
comparatively unfrequent in adults, in whom, however, the symp- 
toms are commonly of a more aggravated character. 

Fortunately for the human race, this fearful malady very rarely 
attacks the same individual more than once, nor have I ever met 
with an unequivocal exception to the rule.] 

The pure congestive disease is rare ; but it is very common to see 
the mixed disease, that is, a combination of the inflammatory with 
the congestive symptoms. 



SCARLET FEVER. 151 

The inflammatory form of scarlet fever generally makes its attack 
in the following manner: — rigors, or only slight chilliness, followed 
by more or less pyrexia, restlessness, want of appetite, thirst, want 
oi' sleep, headache, some degree of nausea, oppression at the prae- 
cordia ; tongue at first slightly loaded, red, with raised papilla? ; or 
it may be much loaded with a yellow fur, and intensely red at the 
tip and round the edges. [The appearance of the tongue is charac- 
teristic. For the first few days it is usually covered with a white 
fur, as in ordinary fevers ; but this sooner or later gives place to a 
uniform shining red colour, while the whole surface is studded with 
the inflamed papillae which appear to take on the eruptive irritation, 
becoming elevated, sensitive and intensely red. In fact, the tongue, 
under these circumstances, has been aptly compared to a piece of 
raw beef. As the eruption declines on the surface, the tongue, in 
favourable cases, resumes its healthy appearance ; but if the diseftse 
should be protracted and typhoid, the tongue becomes dry, brown 
and cracked or fissured ; or perhaps assumes a smooth, glossy aspect, 
which is usually indicative of slow convalescence.] Soreness of the 
throat is complained of, which is sometimes the first cognizable 
symptom; it is either slightly swollen and much inflamed, or of a 
dusky hue, without much swelling ; ash-coloured ulcerations may 
often be discovered, but we must be upon our guard not to mistake 
exudations of coagulable lymph for ulcerations. In the generality 
of cases, there are evidences of subacute inflammation in the larynx 
and bronchi, which is announced by difficulty of breathing, cough, 
and hoarseness, and more particularly by auscultation ; but the in- 
flammation in the bronchial tubes is not so decidedly marked in all 
cases of scarlatina, as in measles and small-pox. Sometimes there 
is delirium, but perhaps during the course of the night only, and 
sometimes some degree of coma. These symptoms may continue for, 
4, 5, or 6 days, before the rash makes its appearance. Some- 
times, indued, the eruption is the first symptom which announces the 
complaint, but this happens in the mildest cases only.* In general, 
the eruption appears <»n the 4th or 5th day. 

The eruption is of a scarlet colour, first to be observed on the face 

and Deck, and in the course of twenty-four hours becomes pretty 

generally diffused, patches appearing here and there more intensely 

red than the surrounding parts; on pressing with the finger a white 

. is left, but the redness returns in a moment afterwards. 

[The rash begins in points or dots, and from these centres it 
soon spreads over the surface, first appearing on the face, breast and 
neck, and subsequently pervading more or less the body and extremi- 
ties. On the latter, it Bometimes causes an obvious elevation of the 
papilla winch feel rough to the touch and present some analogy to 
the eruption <>f measles. The rash begins to decline about the fifth 
day. I have, m Borne rare cases, observed the eruption to be attended 
at its very commencement, with an intolerable itching of the skin; 
and 111 one instance 1 was led to pronounce a patient affected with 

■ met with a remai lion to tin- rale in a child) In whom the 

ymptoms, and yet the disease suddenly 
assumed a most aggravalol l<>rm.] 



152 SCARLET FEVER. 

the nettle-rash, who was actually labouring under scarlet fever, which 
in the end proved to be one of the most violent cases I have ever 
known to recover. Dr. Rush and others describe another eruption 
which they have sometimes observed about the fifth day of the 
ordinary rash, and constituted of semi-globular vesicles, containing a 
thin pearl-coloured serum, whence, in some of the older nosological 
works is derived the name of Scarlatina variolosa. I have never 
seen a case of this pustuloid form of the disease.] 

After the eruption has existed from three to five days, it begins to 
decline; the cuticle subsequently separates and peels off. This is a 
very dangerous stage of the disease, and would be still more so, 
were it not that the eruption declines gradually, and that the circula- 
tion on the surface is still actively employed in the formation of new 
cuticle for the whole surface. 

[■The desquamation in scarlatina is peculiar. On the body, face 
and scalp it mostly takes place in bran-like scales; but where the 
epidermis is thicker, as on the hands and feet, the cuticle sometimes 
comes off entire like the fingers of a glove, leaving the subjacent 
papillae distinct and sensitive for many days.] 

Dr. Gregory, in his lectures, used to state, that " a copious efflo- 
rescence is a favourable symptom : when it is deficient, the symp- 
toms are more severe ; and when it is repelled, it never fails to ag- 
gravate both the general fever and the topical affection of the throat." 
"It is not an easy matter," continued he, " to explain the connection 
which subsists between the efflorescence and the other symptoms; 
it is not critical, but all the symptoms are much relieved by its com- 
ing out copiously." 

Occasionally anasarca, and more rarely ascites, follow in the first 
or second week, and are attended with constipation, scanty urine 
highly albuminous, languor, nausea, general uneasiness, and other 
symptoms which have been denominated secondary fever. 

[It is also not unusual to see inflammation and suppuration of the 
glands of the neck, sometimes extending to both sides, and causing 
great destruction of the parts involved. These glandular enlarge- 
ments commonly take place subsequent to the inflammation of the 
throat; the extension of the one being proportionate to the violence 
of the other. This affection is sometimes very rapid in its develop- 
ment, the glands becoming hard, isolated and egg-shaped : and when 
this happens simultaneously on both sides of the neck, the larynx 
suffers greatly from mechanical compression, even to a fatal degree ; 
the patient dying with all the symptoms of suffocation, owing, how- 
ever, in part, to the tumefaction of the tonsils. 

There is another appearance not so often met with, but much 
more to be dreaded — the hemorrhagic form of scarlet fever. It 
usually commences by small purpurous spots under the cuticle of the 
chest and extremities. Some oozing of blood next follows from the 
mucous membrane of the mouth and nose, which sooner or later 
becomes profuse, and the patient eventually bleeds to death. If a 
vein has been opened in the arm, or an abscess lanced in the neck, 
the incisions become a source of haemorrhage ; and in a case that oc- 
curred in my practice in the winter of 1834-5, and which was seen 



SCARLET FEVER. 153 

by Drs. J. Rhea Barton and Wood, the abscess in the neck suddenly 
filled with blood, and the latter making its way through a leech bite, 
flowed out as if from a divided artery, and destroyed the patient in a 
few hours.*] 

Appearances on dissection. — In the dissections which have fallen 
within my observation, the inflammation and ulceration in the throat 
have not appeared so extensive and important as had been imagined 
before deaih. The most constant diseased appearances have existed 
in the air passages, presenting inflammation in its different stages; viz., 
vascularity of the mucous membrane, thickening, and occasionally, 
ulceration; in two cases I have seen the epiglottis nearly destroyed 
by ulceration ; and also effusion of thick, tenacious matter, filling 
up the air passages to the bifurcation, and often lining the trachea. 
Sometimes the substance of the lungs is seen inflamed, and occasion- 
ally the pleura, but traces of inflammation in these two tissues are 
not so frequently met with, and are to be regarded more as exam- 
ples of acute action, extending from one tissue to another by conti- 
guity, than as forming essential parts of the disease. The lungs are 
sometimes so much gorged with blood, as to have lost in a great 
degree their natural appearance and buoyancy. In the brain there 
is sometimes arborescent vascularity, with turbid effusion between 
the arachnoid and pia mater, and the ventricles are occasionally filled 
widi serosity. On opening the abdomen, the peritoneal coat of the 
Stomach and bowels generally looks healthy, except in the conges- 
tive cases, when the smallest blood-vessels will be seen distended 
with dark-coloured blood. In different parts of the mucous mem- 
brane, we frequently see considerable vascularity, sometimes ulcera- 
tion. The liver is often gorged, or soft in texture. 

" From a cautious survey of the symptoms during life," says Dr. 
Armstrong, in his work on scarlatina, &c, page 16, ''and from the 
examination of several bodies after death, I am warranted in affirm- 
ing, that the brain, the liver, the stomach, the intestines, and the 
IllOgS, .tr<' tli'' pans most often inflamed, and that the inflammation 
m these parts is generally the cause of death, together with the affec- 
tion of the throat." 

Treatment. — In scarlatina, as in other diseases, differences in 
pathological opinions have of course given rise to dissimilar methods 
of treatment. Some, considering it a disease of debility, recom- 
nuend bark, and wine, or brandy, with nourishment, and condemn 
antiphlogistic means ms highly dangerous; in this class of symptoma- 
tica! writ-Ts Bland l Inderwood and Dr. James 1 lamiltonjjun. It will 
lirprise my readers, that tin: first named individual, who did not 
live I. hi.' enough to profit by modern pathology, should have taught 
the doctrines thai prevailed in his own time; but considering the 
.ice, unit winch every author gives of the symptoms and course of 

tins disease, and the appearances on dissection, it is lamentable to 
t that there is .me- author of the present day, who speaks doubt- 
fully even of local bleeding in scarlatina, and who recommends cor- 
and nourishment, and even wine itself, in large quantity. Hut 

[• Bee Purpura, vol. 9, in. VII, chap. 7.] 



154 SCARLET FEVER. 

all this does Dr. James Hamilton, jun. ;* he goes even the length of 
quoting a great medical authority, the head master of a boys' school 
in Yorkshire, in whose practice, among the said boys, " it ivas found 
that children under fifteen years of age, affected with this disease, 
required, ivithin the twenty-four hours, sometimes not only a bot- 
tle of port-ivine, and another of raisin, but also a proportion of 
brandy '."t — Poor boys! 

Underwood, in describing the treatment necessary in this disease, 
makes the following extraordinary statement: « Should the affection 
of the throat, therefore, be evidently inflammatory, or should a case 
occur where the fever may seem to be of that kind, (which may be 
better ascertained by the hardness of the pulse than any other symp- 
tom,) it will very rarely bear bleeding, even in the beginning of the 
disease, as symptoms of debility generally attend in some period of 
the scarlet fever, and will allow only of that middle course of treat- 
ment hinted at above. In a general way, a cordial plan is required 
throughout the disease.";}: And yet, on turning to the next page, it 
will be found he recommends bleeding in the secondary fever; and 
he also tells us, that a critical bleeding from the nose has saved life, 
when the patient's state " has appeared very hazardous, and the 
prostration of strength been considerable." 

In the slighter forms of scarlatina, very little treatment is necessary, 
further than confinement, attention to the bowels to keep them free, 
and the antiphlogistic regimen. In such cases, however, the medical 
attendant should be careful to watch diseased action, at the period 
when the eruption naturally declines, for reasons already mentioned. 
Formerly, I saw many fatal cases of scarlatina, when I practised 
according to the opinion of the schools, carefully abstaining from 
blood-letting, and using all the means recommended to support the 
strength ; but I occasionally observed patients snatched from the 
grave by considerable bleedings from the nose, and at times when it 
was thought the loss of an ounce of blood would prove destructive. 
These circumstances, together with the appearances found on dis- 
section, led me to bleed in many subsequent cases, and I have never 
had occasion to regret it. Blood has been drawn at all periods of 
the disease, in cases where the state of the lungs and brain required 
it; and should the operation be performed during the period of the 
eruption, it will disappear, if a sufficient quantity of blood be taken. 
When the inflammation of the throat runs very high, I know no 
remedy productive of such certain and immediate good effects as 
general bleeding, but should the patient's strength be already re- 
duced, leeches are to be preferred. 

Dr. T. P. Lucas, of the royal artillery, and Dr. Wilson, cannot have 
forgotten the case of Ann M'Farlane, aged 18, which they treated, 
when they were my pupils in the year 1824, from whom they took 
above 3xx of blood, with instant good effect, on the fourth day of 
the disease,' when she had a large sloughing ulcer occupying the 

* Vide his work on the Diseases of Children, p. 380. 

t Management of Children, p. 381, ed. 1824. 

t A Treatise on the Diseases of Children, p. 289. 



[SCARLET FEVER] 155 

whole of the right tonsil. She afterwards required no other reme- 
dies but laxatives, and in a fortnight returned to her usual occupation. 
A great many other gentlemen, who have been pupils at my dis- 
pensary, can be appealed to, and I may refer in an especial manner 
to the testimony of my talented colleague Dr. Robertson, who was 
opposed to the practice of general bleeding in scarlatina, till he saw 
the success of it. [The medical profession in the United States is 
much divided in opinion with respect to venesection. In my own 
practice, I have resorted to it sooner or later, in every severe case, 
and thus far I have no disposition to change my plan. What else 
can we interpose in those violent inflammatory attacks, in which 
the burning skin, swelled throat, excited brain, and universal distress, 
call aloud for relief at the hands of the physician? How yet more 
imperative does this mode of depletion become, when convulsions 
are added to the frightful category ? I am far from recommending 
the free bleedings which are advocated by the author of this work; 
because they would be unwarrantable in the disease as seen in this 
city and its vicinity. But moderate venesection at the outset, re- 
peated, if necessary, has been of all other remedies, that which has 
produced, in my hands, the most gratifying results. The only two 
cases of fatal consecutive dropsy which have occurred in my practice, 
ware patients who had not been bled ; and I have thought that effu- 
sion is more liable to occur in those who, having had the inflam- 
matory form of the disease, were not treated by venesection. Once 
for all, I would exhort the practitioner to discard any proscriptive 
rule with respect to bleeding in scarlet fever. 

In that appalling variety of scarlet fever which is marked, as we 
have shown, by comatose delirium, a cadaverous skin, and the other 
evidences of an essentially malignant disease, every mode of treat- 
ment seems equally unavailing; and I have sometimes been unable 
to satisfy myself that the use of medicines had even the effect of 
retarding the progress of disease. When, therefore, malignant con- 
gestion takes place, our safest course is to apply leeches to the head, 
to maintain the capillary circulation, and consequent warmth by 
every available means, and to give internally, but with great cir- 
cumspection, such medicines as the nature of the case may seem to 
demand It is a great point, under such circumstances, to do no 
harm, \ When general bleeding is either inadmissible, or not thought 

Bary, or when the child is under two or three years of age, local 
bleeding by leeches will be found highly serviceable. When the 
throat it extensively inflamed, although the accompanying symptoms 
may be mild, 1 always think it right to reduce the inflammation by 
the application of leeches, followed or not by a blister, according to 
circumstances. Laxative medicines, frequently repeated, are very 

iary. [Yet blisters, especially when applied to the throat, are 
apt to become gangrenous, and therefore require to be resorted to 
with caution. The safest plan is to leave the blister on until it 

ly reddens the skm, (having first covered it with a line gauze,) 
then remove it and apply a soft poultice, which will complete the 

itory p f oo esi with the least possible irritation. J Sponging the 
body either with tepid or cold water, produces good effects, by allay- 



156 [SCARLET FEVER.] 

ing restlessness. Cold affusion may do no harm in the slighter forms 
of scarlet fever ; but in the severe cases which invariably display 
marks of internal disease, and in which congestion has taken place, 
its use cannot be defended. [In children, especially, the use of a 
warm bath is particularly salutary, both in the hot stage of the fever 
and during the period of desquamation. Warm pediluvia should 
be frequently resorted to ; and when intolerable itching of the skin 
comes on, it may be greatly allayed by sponging with equal parts 
of tepid whiskey and water. I have also found this form of irritation 
to be vastly relieved by the application of any animal oil, and also 
by combining the latter, as lard for example, with lime-water, so as 
to form a preparation resembling the cold-cream of the shops.] 

The tartrate of antimony has been long employed in this country 
in the treatment of fevers and inflammations, and it has been found 
very serviceable in this disease, by controlling the action of the heart, 
and relieving uneasiness. It may be used in the diseases of children, 
by dissolving a grain in four ounces of water, a teaspoonful for a 
dose as often as may be thought necessary. [The safest diaphoretic 
is, perhaps, the citrate of potassa, as recommended in remittent 
fever, to which a little spirits of nitre may be added. If this, 
however, should not be admissible, small doses of the bi-carbonate 
of soda, dissolved in mint water, or some other agreeable fluid, I 
have found to answer a salutary purpose. All the milder alkaline 
preparations seem to be peculiarly adapted to scarlet fever ; whence 
also the use of the chlorate of potassa, as recommended by Dr. 
Watson and other practitioners. A drachm of the salt should be 
dissolved in a pint of water, and this quantity may be taken by an 
adult, as a drink, during the twenty-four hours.*] 

Gargles may certainly be employed, and those of a stimulating 
nature are much lauded ; but it appears to me that the best gargle is 
a little warm water; and I particularly caution young practitioners 
against attempting to syringe the throat of a young child. Inhalation 
of the vapour of warm water, will be found to ease the throat more 
than any other gargle. [But after ulceration or sloughing commences 
stimulating gargles contribute greatly to convalescence. Nothing 
has been found more efficacious in the United States than Cayenne 
pepper, either infused in water, or mixed with vinegar, and fre- 
quently used. Diluted port-wine, the black-oak bark, and common 
green-tea may also be used with salutary effect. The too early use 
of such applications, however, is hurtful for obvious reasons. There 
are other cases in which the application of nitrate of silver has the 
happiest effects, especially in arresting gangrene. It is often best 
put on in the solid form ; but if a solution is desirable, ten grains to 
the ounce of water will be sufficiently active, and this should be 
applied with a camel's hair brush twice or thrice a day.] Opiates 

* [The following are Dr. Watson's exact directions for preparing this medicine. 
Two drachms of the chlorate of potass are to be dissolved in two ounces of hydro- 
chloric acid, previously diluted with two ounces of distilled water. The solution 
must be put immediately into a stoppered bottle, and kept in a dark place. Two 
drachms of this solution, mixed wilh a pint of distilled water, constitute the chlorine 
mixture, of which a tablespoonful or two, according to the age of the patient, may 
be given for a dose, and frequently repeated.] 



[SCARLET FEVER.] 157 

are often serviceable in the last stage, and during convalescence, to 
allay irritability, and procure sleep. [When the glands of the neck 
become much inflamed and swollen, leeches should be at once 
applied to them, followed by emollient poultices, and gently stimu- 
lating liniments. I have often by these means arrested the inflam- 
mation, but it will sometimes go on to suppuration, and form large 
abscesses : when there is no hemorrhagic tendency, these should be 
opened with a lancet, to prevent a scar and circumscribe their 
ravages.] 

Since the alteration which 1 have adopted in practice, I rarely see 
secondary fever or dropsy; but too great care cannot be taken during 
recovery, and the patient should be cautioned against the risk that 
he will run from exposure, errors of diet, and negleciing the state of 
the bowels. Should dropsy take place, it will in general be found 
to be of the acute kind, with coagulable urine, with a specific gravity 
of about 1010°, and will sometimes require the lancet, although brisk 
purgatives, with diuretics, will in general suffice. 

Dr. Lewihs was called to see a little patient of mine, who, after 
scarlatina, had dropsy with coagulable urine. Convulsions suddenly 
appeared when he was much debilitated. Dr. Lewins opened a vein, 
and allowed the blood to flow till the boy (whose age was ten years) 
was relieved ; the blood weighed two pounds. No debility followed, 
and the boy from that time made a rapid recovery, and lias ever 
since been healthy. 

In conclusion, it may be mentioned, that various affections occa- 
sionally follow scarlatina, as inflammation and swelling of the glands, 
and perhaps more particularly of the parotid, which must be treated 
upon ordinary principles. Inflammation often attacks the internal 
ear, leaving a fetid discharge followed on some occasions by incura- 
bl'- deafness, which must also be treated by appropriate means. 
[Such, lor example, as injections of the solution of bicarbonate of soda, 
or sulphate of zinc ; or, where the discharges are fetid, a weak prepa- 
ration of creosote water will answer an excellent purpose. A blister 
behind the ear, repeated from time to time, according to circumstances, 
will aid much in the radical cure of this troublesome affection, which 
not (infrequently terminates in incurable deafness. We often, also, 
icrid discharges from the nostrils, which not only inflame the 
schni iderian membrane so as to cause great distress and pain, but 
they also excoriate the adjacent surface of the lip, and sometimes con- 
tinue month after month with various degrees of irritation. The 

best corrective I have found to he the infernal use of iodine and 

iparilla; with injections into the nostrils of distilled creosote 

water, largely diluted.] These and other appearances following 

itina, are commonly known by the term "dregs" of the disease; 
j Preventive measures. Much has been said and written on bella- 
donna, a> a prophylactic of .scarlatina. It was fust employed for 
tins purpose by 1 lahnemann, who was |< d to its use from observing 
that in small ami repeated doses u produced a slight erythematic 
eruption, some tumefaction of the salivary glands, and dryness of the 
mouth; whence he inferred, from the resemblance these symptoms 
bear to those ofscarlet fever, that it might counteract the infection of 

1 t 



158 MEASLES. 

that disease. He directed three grains to be dissolved in a fluid 
ounce of water, of which three drops were to be given to infants 
under a year old, and to older persons in proportion. 

The use of this preparation as a preventive is purely hypothetical, 
nor is there the least reason to place reliance upon it. Had it 
been employed in the following case, its efficacy would have been, 
in the opinions of some practitioners, perfectly well established. 

A young lady was attacked with high fever, which, at the end of 
the second day, proved to be scarlatina of a severe type. Her parents, 
seven brothers and sisters, and several servants, became apprehen- 
sive of the consequences, and inquired into the propriety of a part 
of them leaving the house for protection against the disease. I gave 
it as my opinion, that as they had been so much in the same atmo- 
sphere with the patient, it would be useless to fly; inasmuch as if 
they were any of them susceptible to contagion they must already 
have imbibed it. They all, in consequence, resolved to remain at 
home; and although they communicated freely with the patient, 
and assisted in nursing her until she recovered, not another member 
of the family took the disease.] 



RUBEOLA.— MEASLES. 

Measles may also be defined to be a disease attended by fever 
and an eruption, which appears at various periods, but generally at 
the termination of the fourth, or beginning of the fifth day, and con- 
tinues for three, four, or five days; after which, some discoloration 
is left on the surface of the body, and occasionally the cuticle sepa- 
rates, but not so invariably as in scarlatina. 

Measles has been divided into four varieties: 
1st, Rubeola vulgaris. 

2d, sine catarrho. 

3d, nigra. 

4th, putrida. 

Pursuing the same pathological plan, which has been adopted 
when treating of scarlatina, I shall also mention two great varieties 
of measles, the congestive and the inflammatory. 

In the first species which has been so well illustrated by Dr. Arm- 
strong, reaction does not take place ; or if it do, it is slight, the erup- 
tion is trivial; the pulse is feeble and oppressed, perhaps quick; and 
the surface is free from that redness and heat which give such a 
striking external character to the pure inflammatory disease. This 
is, no doubt, one form of the complaint called putrid, and which 
has been described by Morton, Huxham, and Watson. The same 
pathology that was maintained in scarlatina, and also in the general 
statement concerning eruptive fevers, equally applies to this case, 
and renders it unnecessary to repeat the observations. 

Capuron, in his treatise on the diseases of children,* makes the 

* Page 293. 



MEASLES. 159 

following statement:— One of the most dreadful complications of 
measles, is that with an ataxic or malignant fever. Individuals 
naturally lively and delicate, as those in infancy, are more subjected 
to it. It is one of those unlooked for anomalies in the vital proper- 
ties. The functions of the brain are disturbed; respiration is de- 
ranged, and becomes extremely constrained; in a word, the patient 
is quickly reduced to the last extremity, if something be not done 
for liis relief. The most active treatment is here indispensably neces- 
sary to sustain life, which is shaken to its very foundation." Sub- 
sequently he states: that "infants naturally weak, or who live under 
the influence of debilitating causes, are exposed to an adynamic or 
putrid fever during the course of the measles. One detects this dan- 
gerous complication by the change in the form and colour of the 
spots; — from being at first prominent and of a lively red, they 
become more depressed, pale, and livid ; in which case, we must pre- 
vent the prostration of strength in good time, and direct the erup- 
tion back again towards the surface of the body by the use of 
tonics, such as wine, bark, and camphor; the greatest advantage 
may be also obtained by epispastics, and above all by" blisters." At 
p. 894, he again observes, "there are infants in whom the progress 
of the eruption is arrested, the spots disappear, and pains in the 
chest, more or less severe, manifest themselves; respiration is op- 
pressed ; peripneumony declares itself; suffocation is threatened.' , 

Mr. Burns, of Glasgow, in detailing the symptoms of measles, 
states, that "sometimes the eruption suddenly and prematurely 
recedes, or never comes fully out. Both of these cases are unfa- 
vourable ; the fever is high, and the oppression great." It will be 
. by consulting the report of diseases treated at the New Town 
Dispensary of Edinburgh, during the last six months of the year 
1816, published in the 13th vol. of the Edinburgh Medical and Sur- 
gical Journal, that this form of the disease was very prevalent, and 
that few children recovered; most of those attacked were of feeble 
habit, or weakened by previous illness, "but others appeared to have 
been quite healthy when exposed to the contagion." Those af- 
I in ibis way were chiefly infants, but a few were children from 
four to seven years <>f age. They were ill longer than usual, gene- 
rally live or six days, before any eruption appeared, having the usual 
catarrhal symptoms, with much debility and drowsiness; frequent 
romiting; generally frequent, and sometimes bloody stools; quick 
i, and white tongue, without much heat of skin. When the rash 
appeared, it was at first less distinctly circumscribed, and afterwards 
ited than usual, of a darker colour, and attended with less 
In at of skin. After its recession, the patients were more or less dis- 
tressed w;th COUgh or dyspnoea, generally with diarrlura, and almost 
always with a frequent ineffectual attempl to vomit. The pulse and 
breathing became very quick; the tongue, after losing the white 

rnM which had covered it at the beginning of the disease, became 

ind hard-, the posture indicated much debility; the countenance 
had lii- languid, vacant expression of typhus; and a dark-coloured' 

fur usually gathered on the lips and teeth. In all these cases, there 



160 MEASLES. 

was a degree of drowsiness approaching to coma; and in a few, this 
state appeared to be blended with delirium. 

In two or three instances, infants exposed to the contagion of 
measles, became affected with catarrhal symptoms, fever, drowsi- 
ness, quick and oppressed breathing, and died, without any eruption 
being observed. 

In the cases of speedy recession of the rash, if the cough and 
dyspncea were urgent after its disappearance, death almost univer- 
sally ensued from the first to the fourteenth day after that change. 
But those in whom the pectoral symptoms were less distressing, re- 
covered from the state above described, under the use of wine and 
cordials, which, as far as we could judge, were as decidedly bene- 
ficial in these as in any other cases in which we have seen them 
used. It should be mentioned, however, that one or two, who 
could not be prevailed on to take either food or medicines, gradually 
mended without any crisis being observed. 

On opening the bodies of those who had died of this form of 
measles, a considerable accumulation of mucus in the bronchia was 
always found. In two infants, under a twelvemonth, there were 
marks of inflammation of the lungs, (which in one of these had pro- 
ceeded to ulceration,) and a good deal of water was found in the 
pericardium. In one child, four years of age, there was such a con- 
gestion of blood in the lungs, that a large portion of them sunk in 
water. 

In several cases, in which the eruption had almost or entirely 
disappeared on the second day, it reappeared that night, after the 
use of the warm bath, and an opiate, and continued nearly the usual 
time. 

An aphthous state of the month and tongue occurred pretty fre- 
quently, but was not confined to the unfavourable cases. 

The circumstances of the livid colour and rapid recession of the 
eruption, of the succeeding typhoid state, and the irritability of the 
stomach attending that state, seem to point out a resemblance be- 
tween the cases of measles now described, and the worst cases of 
scarlatina. 

I scarcely think that such symptoms and morbid appearances sup- 
port the wine and cordial treatment, which, we are told, was had 
recourse to in these cases. It has fallen to my lot to treat a consi- 
derable number of cases of this kind; and the plan which experience 
has led me to adopt, is first to try the warm bath with stimulating 
frictions; but if the symptoms be very threatening, such as coma, 
convulsions, or asphyxia, or an approach to these states, the best 
practice, if the patient be an adult, or even a child, if a vein can be 
found, is to bleed at once. Many interesting cases might be detailed, 
showing the advantage of this plan. The following is a short sketch 
of one. A few years ago, I was called suddenly to see a child in 
measles on the first day of the eruption; every appearance had been 
so favourable up to the moment of the sudden recession of the rash, 
that the family had not applied for medical advice. On my arrival, 
the eruption, which had been extensive, and of the usual colour, was 
not to be seen, although it still was to be felt. The child was under 



MEASLES. 161 

three years of age, and of good constitution; it had had three or four 
strong convulsions in the course of rather less than an hour, and was 
now comatose; one pupil dilated, while the other was of the natural 
size ; the hands were clenched. A good-sized vein being found in 
the arm, was instantly opened, and from eight, to ten ounces of blood 
abstracted when the breathing and every other appearance became 
more favourable; the pulse, which was under sixty, rose gradually 
as the bleeding went on ; and the child soon became quite sensible. 
So far from debility following, it was necessary, from the appear- 
ance of cerebral irritation, to apply leeches next day to the head; the 
child made a rapid recovery, and was running about in the course of 
a week. 

In every respect the treatment must be conducted in the manner 
detailed in congestive fever, as well as in the congestive form of 
scarlatina. 

The inflammatory disease is the form most generally met with ; 
we have the usual eruptive fever, preceded by rigors, depression, 
and debility, along with the fever; the patient has a dry cough, with 
hoarseness; frequent fits of sneezing and coryza. He also complains 
of giddiness and pain in his forehead, as well as in the back; his 
pulse is various, sometimes frequent and small, or frequent and strong; 
often it is irregular and oppressed; the bowels are generally confined, 
and the evacuations fetid. In the course of the second, third, or fourth 
day of the fever, the symptoms run higher; the eyes are tender, red, 
watery, and inflamed; the dyspnoea, which was slight at first, is now 
more severe; the patient complains of tightness of the chest, pain 
and oppression at the praecordia. The eruption appears first on the 
face and neck; in twenty-four hours it is found on the breast, and 
afterwards gradually spreads over the rest of the body ; it consists of 
small red papula?, slightly elevated, resembling recent flea-bites; these 
BOOH form themselves into extensive patches, irregular in shape, their 
margins having somewhat of a crescentic appearance. [The eruption 
nn the face and body is much more elevated than in scarlet fever, and 
of a darker red colour.] The eruption is sometimes very extensive, 
at Others slight. The throat, when examined, will be observed to be 
Covered with small red patches, occasioning dillicult deglutition. 

Sometimes, immediately before the eruption comes out, the patient 
is seised with violent Bickness and vomiting; sometimes with con- 
vulsions; bnt if the eruption subsequently comes out freely, these 
lymptoms abate. 

In a great majority of cases, the disease is rather slight, and the 
internal disturbance, which is discovered by the symptoms already 
described, is generally very much appeased soon after the appearance 
of the eruption, particularly if it come out freely and plentifully. 
ionally, however, the symptoms are very severe from the be- 
ginning; the COUgh is frequeni and harsh; there is considerable 
■ytpnosa, with hoi skin, thirst, and a quick pulse; and the child is 
tonally so lethargic, that this symptom early attracts our atten- 
tion. 

As the embarrassment of the lungs increases, which may happen 
in any Stage, the face becomes discoloured, and sometimes presents 

14* 



162 MEASLES. 

a purple appearance, and occasionally the eruption over the whole 
body assumes a dark colour; this is the state which is called rubeola 
nigra, and is probably that form of the complaint described by Dr. 
Watson, under the term putrid measles. 

After the natural disappearance of the eruption, the fever, dys- 
pnoea, and cough, in some cases increase, attended or not with 
considerable gastro-intestinal irritation and diarrhoea: occasionally 
inflammation of the eyes, and enlargement of the glands of the neck, 
succeed. Blistered surfaces frequently slough ; and it has been re- 
marked by Dr. Watson, Dr. Ferriar of Manchester, and others, that 
an ulceration of a particular character attacks the pudendum of girls, 
from which few recover; four cases have fallen within my observa- 
tion, three of which proved fatal; and it is my opinion that death is 
not owing to this ulceration, but to internal disease. Dissection, in 
two of these cases, displayed extensive disease of the lungs, but more 
particularly ulceration of the mucous membrane of the intestines, of 
which the preparations and drawings are in my museum.* 

Appearances on dissection. — Morgagni notices the following 
case, which, he says, has been transferred from Ballonius into the 
Sepulchretum: " On examining the body of a person to whom it was 
suspected that poison had been given, the stomach was found beset 
with exanthemata, and the physicians were upon the point of assert- 
ing that the appearance was owing to poison, when they were in- 
formed that the person died of measles, which began to appear on 
the skin, and suddenly vanished." 

In the examinations at which I have been present, effusions and 
other marks of inflammatory action have been found in the brain, and 
sometimes ulceration in the mucous membrane of the bowels; but 
I have seen no dissection in which the pulmonary system escaped. 
The lining membrane of the bronchi, trachea, and larynx, has not 
only been found in a highly vascular state, but it has been thickened, 
softened, and occasionally ulcerated ; the ulcers are small, and gene- 
rally situated near the bifurcation; the bronchial tubes are more or 
less filled with a matter like pus or thick mucus, as in bronchitis ; the 
colour of this secretion varies; and it is sometimes tenacious. This 
condition of the air passages has always existed on both sides of the 
chest. In many cases, the lungs are found emphysematous : in 
others inflamed in different degrees; the inflammation rarely affecting 
both lungs, and it is frequently confined to one lobe. Occasionally 
there are extensive inflammations of the pleura, indicated by effusion 
of serum and exudation of coagulating lymph, besides thickening of 
the pleura and recent adhesions. In cases of longer standing, tuber- 
cular formations are observed in different degrees of advancement ; 
sometimes even excavations of the lungs are seen. 

It ought to be noticed, that the inflammatory appearances in the 
brain and bowels, together with the disease of the substance of the 
lungs, and the pleuritic effusions, are to be regarded as accidental 

* This is the disease which has been described in the 7th vol. of the Med. Chir. 
Trans, of London, by Dr. Kinder Wood, who saw twelve cases, of which only two 
recovered. The case of recovery which I have noliced, was under the care of Dr. 
Moffit, of the 7th Hussars ; the patient was a soldier's child. The disease followed 
a very slight attack of measles. 



MEASLES. 163 

circumstances; whereas, the inflammation of the bronchial mem- 
brane is an essential part of the disease, and may be traced from the 
beginning of the complaint. 

Treatment. — In the slighter forms of this disease, as in scarlatina, 
very little treatment is necessary, further than confinement to one 
room, the exhibition of gentle laxatives, and low diet. The medical 
attendant should be still more watchful in this disease than in scarlet 
fever, at the period when the eruption naturally recedes, for reasons 
already mentioned. In the severe forms of measles, bleeding is often 
necessary during the eruptive fever, when the pectoral symptoms 
run high and appear threatening; and also when coma and convul- 
sions take place, both of which are more likely to happen, but parti- 
cularly the latter, if the child be suffering from difficult dentition. I 
was called to see a fine boy of two years of age, who, during the erup- 
tive fever, was seized with convulsions in the night, at the period 
when the eruption ought to have made its appearance, and from whom 
nine ounces of blood were taken. Next day he had nine or ten 
leeches applied to his head: the symptoms were afterwards exceed- 
ingly slight, and he made a rapid recovery. He bore the bleeding 
without any tendency to syncope, while his brother, a boy of twelve 
years old, labouring also under the same disease, and who required 
blood-letting for pectoral symptoms, fainted upon the loss of two 
ounces. 

When bleeding is necessary, it ought to be performed in the man- 
ner already described when treating of inflammatory fever; a suffi- 
cient quantity should be taken as early as possible in the disease, 
and the operation ought to be repeated at short intervals; but when 
the bronchitic symptoms have been allowed to go on neglected till 
the air passages are gorged with mucus, bleeding is a very question- 
able remedy, and no doubt often does irreparable mischief, for reasons 
which will be fully noticed when treating of bronchitis. Leeches 
are to be employed as directed in scarlatina, and also blisters.* An- 
timony is also highly serviceable; and opiates in the last stage, when 
there are restlessness and irritability, if the air passages are not filled 
with mucu& The warm bath affords much comfort to the patient 
in all the exanthemata, every night, or every other night, after the 
eruption has declined, and when the cuticle is exfoliating. During 
recovery, gmat attention should be paid to the diet, clothing and 
state of the bowels, so as to avoid the disagreeable circumstances 
which so often follow the exanthemata, viz., the formation of tuber- 
cles in the lungs: inflammation and ulceration of the mucous mem- 
br.iin- of the bowels, producing the disease which is called tabes 
■eeenterica; and also glandular affections of the neck, inflammation 
of the eyes, and chronic eruptions of the skin. 

This is a very different line of treatment from that which is still 

recommended by Dr. James Hamilton, jun., and which is founded 

Opon the most curious notion that can well be conceived, viz., that 

1 symptoms in measles are not occasioned by inflammation, 

• W i ;. ■ Mistei I 10 a child, under any circumstances, the part should 

i I v examined daily by the medical attendant, but more particularly in Lbfl 
eruptive lev. 



164 SMALL-POX. 

but by "torpor of the lymphatics" But as this statement may not 
be credited, Dr. James Hamilton, jun., shall be allowed to speak for 
himself. At page 377 of the work already quoted, last edition, the 
following passage will be found: '-As the debility which always 
attends and follows measles is the most prominent feature in the 
progress of the disease, it is not easy to understand the reasons why 
practitioners have been led to overlook so obvious a circumstance. 
The objections to wine and nourishing diet, which it is so often ne- 
cessary to combat, probably arise from the supposition, that the fre- 
quency of the pulse and the cough are the effects of inflammation, 
when in fact they are occasioned by the torpor of the lymphatics V 
[Inoculation in measles. — Many experiments have been tried at 
different periods, for the purpose of testing this important operation ; 
but they have, for the most part, been fruitless and unsatisfactory. 
It has recently been asserted, however, that Dr. Von Katona, of 
Borsoder, in Hungary, has succeeded in inoculating 1122 persons by 
taking the fluid from the vesicles, or a drop of the tears from a pa- 
tient labouring with the disease. The operation is said to have been 
performed in the same manner as the inoculation for small-pox. It 
failed in seven per cent, of those on whom it was tried ; but all the 
others took the disease in a mild form, and not a single death oc- 
curred. The puncture was immediately surrounded by a red areola, 
which soon disappeared. On the seventh day the fever set in with 
the usual premonitory symptoms of measles; on the ninth day the 
eruption appeared ; on the fourteenth, desquamation commenced, 
with decrease of fever and eruption; and by the seventeenth day the 
patients were, in general, well again.] ■ 



SMALL-POX.— VARIOLA. 

[It is an interesting and remarkable fact, that small-pox does not 
appear to have been known to the Greeks or Romans, although 
there is abundant evidence of its having prevailed in Chitia and 
other parts of Asia from the remotest times. It appears, indeed, to 
have been introduced from India into Arabia, about the sixth cen- 
tury of our era, and then spread rapidly into Syria and over the 
whole of Europe. In later times it has been conveyed by trading 
vessels and overland caravans to every part of the habitable earth, 
constituting the most widely spread pestilence to which the human 
species is subject.] 

Small-pox is generally divided into three varieties, viz., 1. Distinct ; 
2. Confluent; 3. Modified. The first obtains that name when the 
pustules are distinct, and do not run into each other ; the second is 
denominated confluent when the pustules are very numerous, and 
coalesce ; the third variety is so named from the influence of certain 



SMALL-POX. 165 

well-known causes that modify the disease, and render the symptoms 
less severe, and the cases less dangerous. 

This disease commences with rigors, followed by febrile symptoms, 
which continue from forty-eight to sixty hours, and even longer before 
the eruption appears; and it is no uncommon thing for children to 
be seized wilh convulsions during this period. The attack is fre- 
quently very sudden; vomiting generally occurs ; there is pain in 
the head and back; and the patient complains very much of oppres- 
sion at the praecordia, and pungent paiu in the pit of the stomach, 
much increased on pressure ; there are also decided marks of general 
disease of the mucous membranes, and more particularly that of the 
bronchi, announced by dyspnoea, cough and wheezing. 

The eruption first appears on the face, in the form of small red pa- 
pula? and afterwards extends over the rest of the body. About the third 
day, a vesicular appearance is observed on the top of each spot, 
which is soon depressed in the centre, and is found to contain a 
transparent fluid, with an inflamed circular margin. About the sixth 
day tin- eruption loses the depression in the centre, and instead of 
serum, will now be found filled with a puriform matter. When the 
pustules are numerous, the parts swell much, and the neighbouring 
skin is of a red colour, from the extension of the inflammation. About 
the seventh day, some of the pustules on the face burst, and upon 
the eighth or ninth they begin to dry and scab over the rest of the 
body. The swelling, which affects the face, hands, and feet more 
severely than other parts of the body, gradually declines ; the skin 
remains of a dark-brown colour after the scabs fall off, and it is 
many weeks before the surface recovers its natural appearance. 

This is the course which the distinct small-pox generally runs, and 
when treated properly it is rarely fatal, every thing depending upon 
the state of the lungs and brain. 

In the confluent small-pox, all the precursory symptoms are more 
severe; the eruptive fever runs higher; pain in the epigastrium; and 
dyspnoea are more complained of; convulsions and delirium also 
more frequently take place ; and the patient runs more risk of second- 
ary fever, and danger from extensive inflammation, ulceration, and 
sloughing of the skin. 

In both varieties, but particularly in the confluent, copious saliva- 
tion sometimes tal . and soreness of the throat is a marked 
symptom; upon examining the mouth and fauces, vesicles or pus* 
Riles may be observed on the tongue and as far down the pharynx 
as the eye can reach. I have seen the same appearance on the mu- 
ooufl membrane of the rectum, in a case of small-pox in which there 
u-.is prolapsus ani; and in the year 1623, a great number of my 
pupils had an opportunity of Beeing a similar case. I am not aware 
whether this appearance in the fauces and rectum follows an increase 
and declines simultaneously with the eruption on the skin. In some 
severe cases, petechias are seen, when the eruption has begun to 
decline; bloody vomiting and diarrhoea, with tenesmus, take place, 
an l the dyspnoea frequently increases as the disease advances. 

The inflammation in the skin is frequently so deep and severe, 
that the death of B portion takes place, perhaps of the cellular sub- 



166 SMALL-POX. 

stance, as in carbuncle, and this is one cause of what are called pock- 
marks. 

In small-pox, as well as in other acute diseases, there is a congest- 
ive form, in which the system is unable to raise sufficient reaction; 
there is consequently more oppression ; the surface is pale; the erup- 
tion flat, and never matures properly; the dyspnoea is very consider- 
able; and I verily believe this is the form which is called the most 
malignant. 

In severe cases, death takes place before the eighth day ; but 
generally speaking, the fatal event happens sometime between the 
tenth and seventeenth days. The proportion of deaths is said by 
Dr. George Gregory, who must be a very good authority upon this 
subject, to be about one in every six persons who receive the small- 
pox in the natural way. But during the prevalence of an epidemic, 
the mortality is sometimes one-half. Indeed, it appears that during 
a severe epidemic at Ceylon, in 1819, the number of native inhabit- 
ants taken into hospital at Kandy, amounted to 931 ; of these 525 
died. Since the publication of the first edition of this work, I had 
occasion to attend 50 cases of small-pox, all of which were distinctly 
traced to the imprudence of a woman who exposed her unvaccinated 
child to the contagion, when visiting a sick friend. Of these 50 patients 
35 had gone through the process of vaccination ; 15 had never been 
vaccinated, (they were infants under one year of age.) All the 
protected cases recovered. Of the 15 unprotected cases, 10 died. 
Three only of the 15 had the disease slightly. Of the 5 children 
who survived the attack, one did not recover perfectly, and died of 
chronic bronchitis some months afterwards. 

Appearances on dissection — Head. — I have seen marks of inflam- 
mation of the membranes, evinced by a considerable arborescent 
vascularity on the surface of the brain; the vessels of the pia mater 
being greatly loaded with blood, together with effusion under the 
arachnoid, and into the ventricles. But it becomes me to speak with 
diffidence with respect to this part of the subject. Dr. George 
Gregory says, at page 105, that he has "never been able to trace 
any morbid appearance in the head," which is rather at variance 
with the results of my limited experience, and with a statement 
which he subsequently makes at page 108. In directing the mode 
of treatment, he says, "It is to be remembered also, that in small- 
pox, fully as much as in any other form of fever, there is a tendency 
to congestions and inflammations in the head and thorax." "A 
patient," (says Batting, p. 76,) "During the cure of a very extensive 
fracture of the skull, was seized with small-pox, &c. It was curious 
to observe in this patient the appearance of variolous pustules upon 
the granulations of the dura mater." 

Although 1 have been prevented, by the impatience of surviving 
friends, from opening the head as often as I could have wished, yet 
many opportunities have been afforded me of examining the contents 
of the thorax and abdomen. I have seen pustules in the pharynx, 
larynx, trachea, and oesophagus, in those who died on or before the 
twelfth or thirteenth day, on some occasions closing up the larynx ; 
the mucous membrane of the bronchi very vascular, and the air tubes 



SMALL-POX. 167 

completely gorged with matter, most frequently of a reddish colour ; 
but in no instance have I been able to discover a pustular appear- 
ance below the bifurcation; the substance of the lungs gorged with 
blood, and in the first and second stages of inflammation ; and in 
one instance there was pleuritic effusion. On examining the body of 
a deformed girl, who died under an attack of confluent small-pox, 
the peritoneum and pleura were studded with small circular spots, 
which looked like a faded eruption, but perhaps they might have 
been produced in the manner which we sometimes see in cases of 
purpura. I have observed nothing in the stomach to account for the 
severe burning pain complained of in the epigastric region; the 
mucous membrane has certainly shown vascularity, and has been 
covered with a viscid exudation, the follicles being much increased 
in size, which appearance often extends throughout the whole in- 
testinal tube. In three or four instances, I have seen ulcers having 
a pustular appearance, with a depression in the centre, in the jeju- 
num, ileum, and also in the large intestines, of which the preparations 
and drawings are in my museum; and some of them were surrounded 
by an inflammatory areola. 

Treatment. — Small-pox under every form is a serious disease; for 
however mild it may appear in its attack, its consequences are always 
to be dreaded. The confluent, however, is a very dangerous disease; 
and we are to be guided in the treatment by observing the state of 
the brain, and the organs contained within the thorax, as well as the 
condition of the surface of the body. 

It was formerly the custom to keep patients very hot, and to 
employ stimulants ; and the consequence was, that the mortality was 
immense : but for many years past, patients have been kept cool, 
and the antiphlogistic regimen recommended, but, I fear, too little 
practised, from the dread of putridity. Bleeding has been often 
employed, and strongly recommended, in this disease, particularly 
dining the eruptive fever; but it has as often been condemned, be- 

e it destroyed that strength, which, it is alleged, is so much 
r< quired to the latter stages of the disease. But the same language 
is used in the purest inflammatory fevers. In all the successful cases 
of coofltieot small-pox occurring in adults, which I have treated, 

pi one, amounting io all to about eighteen, bleeding was em- 
ployed, and largely employed, in the eruptive fever, to moderate 
what was thought to be local inflammation, without suspecting that 
they were cases of small-pox; several 'of the sufferers were my 
pupils, who had had themselves bled before they sent for me. In a 
Dumber of instances, blood has been drawn even after the appearance 
of the eruption, and with decided benefit; but upon the whole, it is, 
perhaps, best at that period to trust to leeches for relieving local in- 
flammations. The state of the throat ami air passages requires daily 
and minute examination; and alter the eruption comes out, the 

ication of leeches is often necessary to the neck, and also to the 

'. to reduce inflammation. Bleeding before the appearance of 
llM eruption may be expected to moderate that symptom, which is 
ot iii" greatest consequence, as many die from toe severity and 
extent of the external inflammation. The appearance of petechia: 



168 [MODIFIED SMALL-POX] 

does not prevent me from ordering the application of leeches, in cases 
which require this practice. With respect to other points of treat- 
ment, they are similar to those which have been recommended in 
scarlatina, measles, and other febrile diseases. I may be allowed, 
however, on this occasion, to insist on the propriety of trusting to 
nature a little more than is generally done, when the patient begins 
to convalesce ; avoiding attempts to hurry it on, and restore the 
strength, which, in a great proportion of cases, is the cause of 
secondary fever. A number of disagreeable circumstances often take 
place as sequels of small-pox, and the most painful one is the forma- 
tion of boils on various parts of the body, and sometimes even car- 
buncles, of which there are successive crops tormenting the patient 
for weeks. Glandular affections also frequently follow, as well as 
ophthalmia tarsi and ophthalmia purulenta. I can state from 
experience, that it is a good plan to open the pustules on the face 
early, in order to prevent marks. [It is somewhere suggested that 
this object may also be attained by keeping the patient in a dark 
room, a practice which I have not found to produce any sensible 
effect. A plan I have adopted with great success, is to have the face 
frequently wet with spirits of hartshorn, which keeps down the in- 
flammation, and prevents the pustules from becoming either large or 
irritable. M. Velpeau asserts, and I have confirmed the truth of his 
statement, that if the pustules of small-pox are cauterized within the 
first two or three days, or even somewhat later, their duration is 
abridged, and no marks ensue. The best mode of applying the 
caustic, is to cut it to a fine point, and pierce it through the centre of 
each pustule. Other practitioners have recommended the free appli- 
cation of mercurial ointment to the pustules with a camel's hair 
brush when they are distinct, or put on with a feather in confluent 
cases. Dr. Olliffe, of Paris, speaks in the strongest terms of the 
plaster of vigo, of the French Pharmacopoeia, an article which is 
composed chiefly of mercury made into a soft plaster with styrax 
and other ingredients; but notwithstanding the preference ascribed 
to this preparation, it can have little, if any advantage, over simple 
mercurial ointment. 

Dr. Midaveine has used sulphur for the same purpose with satis- 
factory results. His formula consists of two drachms of sulphur to 
an ounce of lard, which ointment is gently applied to the eruption 
three times a day. 

Gold leaf is employed by the Arabs and Egyptians to prevent the 
cicatrices of small-pox; and on the testimony of Baron Larrey it is 
highly efficacious. The gold leaf is applied on the first appearance 
of the eruption on the face, hands, neck, &c, and is kept in contact 
with the skin by means of gum-arabic mucilage. Baron Larrey also 
derived evident advantage by simply anointing the face freely with 
olive oil. Some of these articles appear to act simply by excluding 
the atmospheric air.] 

Varioloid. — Modified Small-Pox. — There are several circum- 
stances which are said, in medical language, to modify this horrible 
disease. The mysterious power of vaccination in preventing small- 



[VARIOLOID— MODIFIED SMALL-POX] 169 

pox is now admitted; experience, however, has taught us, that this 
antidote does not always succeed; but the generality of cases of 
small-pox, which follow vaccination, are very mild. Individuals are 
sometimes attacked also a second time with small-pox, and in my 
comparatively limited experience, I have known upwards of twelve 
well-authenticated instances. The first attack is generally supposed 
to modify the second, and to render it milder; hut it is curious, that 
all my cases of secondary small-pox, with the exception of two, 
were remarkably severe; whereas, I have rarely seen a severe case 
of small-pox after vaccination. 

Previously to the great discovery of Dr. Jenner, respecting the 
power of vaccination in preventing small-pox, the disease was mo- 
dified, and rendered less severe and fatal, by inoculation. This 
practice had been long followed in the East, and was introduced 
into this country from Turkey, by Lady Mary Montague.* 

An interesting question arises, to determine why the inoculated 
small-pox should be so much milder than the natural? 

This is, perhaps, easily answered. A proper season of the year is 
chosen for the operation; the patient undergoes a certain preparation, 
and his bowels are particularly attended to. 

In the modified disease, the stages are all shorter, and the eruptive 
fever is slighter; the convalescence is less tedious, and the sequelae 
are not so troublesome. 

This disease must be treated according to the general principles 
already laid down. 

[Varioloid. — The modification of disease, to which this name has 
been given, has excited a deep interest for many years past ; yet, not- 
withstanding the zeal and talent of the many observers who have 
turned their attention to it, it remains a disputed question, whether 
variola and varioloid spring from an identical contagion For, al- 
though I am myself convinced of this identity, many distinguished 
physicians, in all parts of the world, are of a contrary opinion. Let 
us DOW examine into the prominent facts connected with this inquiry. 

The accession of varioloid in persons protected by vaccination, is 
usually in the form of a mild small-pox. Tims, lite lever, though 
sometimes considerable, is seldom violent, and subsides greatly, oar 
even disappears on the occurrence of the eruption. Tin; latter ap- 
pears first in ,i papulous form; in other words, in small red. conical 
elevations of the cuticle, with some inflammation at the base. In 
some cases these papula' fill rapidly with a tnrpid or milky thud, and 
are dry and disposed i<> desquamate by the fourth or fifth day. Ex- 
amples of ilus kind bear a close resemblance to varicella, and have, 
no doubt, been mistaken lor thai disease. 

In other cases, however, the eruption differs little or nothing, in 
its physical characters, from that of genuiue small-pox: lot the lim- 
pid thud at fust noticed in them, becomes purulent,? the pustules are 

• a i) mu 

[ ' i»i alben i Qermao physician, and several other author* assert, that the pjm- 
i .i .iM never ci. iii. hi. pot— a statement ton orach ai rariance with common 

" niiuiri- an argument to disprove H ] 



170 [VARIOLOID.] 

large, well defined and flattened, and have a distinct central depres- 
sion. Although the desquamation is usually completed within the 
sixth day, it is sometimes extended to the sixteenth. 

The scabs are thin and diaphanous, of a dark straw or light brown 
colour; as they fall off, they leave the surface marked by a tubercu- 
lated elevation, rough to the touch and obvious to the eye ; but pits 
or scars are of extremely rare occurrence. 

Secondary fever seldom or never occurs; and the patient is usually 
convalescent from the completion of the eruption. 

The pustules are almost invariably distinct in their character, nor 
have I ever met with an approach to the confluent form. They are 
most numerous on the chest, neck, at the bend of the arm and on the 
face ; but in many instances the whole eruption has been confined to 
a very few pustules, and sometimes to one pustule only. The erup- 
tion, moreover, is apt to assume a mixed character; some of the 
pustules continuing papulous throughout, and never becoming puru- 
lent : while others, in the same person, will have all the appearances 
of true variolous disease. 

In persons, who have had the genuine small-pox, the varioloid 
does not differ materially from the form just described. 

It is remarkable, however, (and the fact constitutes a stumbling- 
block in the study of this disease,) that varioloid sometimes occurs 
in persons who have had neither variola nor vaccine. Dr. Thomson 
has recorded his experience in several cases of this nature; and later 
observers have incontestably corroborated his statements. For my 
own part I have never seen an example of this kind, and shall there- 
fore quote from Dr. Thomson a few remarks on this particular modi- 
fication. . He observes that in this class, the eruptive fever has in 
general been severe, though in some cases mild and of short dura- 
tion ; but usually continuing three days before the eruption came 
out. The latter was sometimes papulous at first, soon becoming 
vesicular; but, in a majority of cases, the papulae became distinctly 
pustular at an early period of the eruption, assuming the characters 
of distinct small-pox; the pustules, however, varying in the time of 
their appearance, sometimes coming out simultaneously over the 
whole body, and in other instances appearing in successive crops. 
Even in these unprotected constitutions, the disease is much milder 
than casual small-pox ; the fever is of shorter duration; the pustules 
often want the central depression, and are mostly matured by the 
sixth day; cicatrices seldom follow the desquamation, and secondary 
fever is unusual. 

The preceding facts have led some pathologists, erroneously, we 
think, to consider variola and varioloid as distinct contagions ; but 
they at least overthrow the familiar postulate, that varioloid is 
always and only small-pox modified by vaccination; unless from 
the comparatively small number of cases we assume that the excep- 
tion proves the rule. 

It is also said, by some pathologists, that whilst in variola the 
chorion, or cutis vera, becomes the seat of a phlegmonous inflamma- 
tion, ending in suppuration, and followed by loss of substance, vari- 
oloid is a lymphatic phlogosis of the most superficial layer of the 



[COW POX— VACCINATION.] 171 

integuments ; hence, also, the groundless inference that the two mala- 
dies are developed under the influence of different contagious agents. 

The following brief history will serve to illustrate the identity of 
small-pox and varioloid; and there are, perhaps, few physicians in 
extensive practice who have not met with analogous examples. I 
was called to see a black man servant with a violent fever, which 
soon developed the characteristic small-pox eruption with great 
severity, and of the mixed, distinct and confluent kind. This man 
had never been successfully vaccinated. The gentleman of the 
house, a man of forty, who had been carefully vaccinated in infancy, 
was next attacked ; he had a high fever, followed by a plentiful erup- 
tion, which, however, was distinct, and the recovery took place at 
the usual time. There were, also, in the house, three children from 
five to nine years of age, all of whom had been vaccinated in early 
infancy by my own hand ; they all had an active fever ; two of them, 
had about a dozen or twenty abortive pustules, and the third had a 
solitary pustule on the forehead. In the servant, who was unpro- 
tected by previous vaccination, the cicatrices left by the small-pox are 
everywhere abundant. In the gentleman there is no remaining 
trace of the eruption, nor is there any in the children. All these 
various modifications of disease were derived from the same conta- 
gion, influenced solely by vaccination or its absence, and the period 
ol time which had elapsed since its use. What was confluent small- 
pox in one became a mild disease in another; while in the children, 
in whom the vaccine was yet active, the disease was so slight, that 
but for the collateral circumstances, it might never have been identi- 
fied even as a varioloid infection. 

The treatment of varioloid is such as would be resorted to in mild 
small-pox— saline aperients and diaphoretics, and a light, cooling 
regimen.] 



[COW-POX.— VACCINATION.] 

[We owe the discovery of vaccination to Dr. Jenner. He observed 
that those persons who milked cows affected with the disease called 
eotihpox, were exempt from the small-pox — whence he inferred that 
an equal immunity might be derived from the artificial insertion of 
tin: virus of th<- former eruption. Experiments proved the truth of 
this inference, and vaccination is now justly regarded as one of the 
test benefactions that medical science has bestowed upon the 
human race. 

Dr. Jenner's discovery was fust published by him in 1798, and 
Vaccination was introduced into the United States the year fol- 
lowing. 

It bad long been known that a disease called the grease, in horses, 
was sometimes communicated to tin? cow by persons employed in 
dressing the heels of the one, and afterwards in milking the other. 



i72 [VACCINATION.] 

Dr. Jenner, in the outset of his inquiry, supposed this disease to be 
the origin of the small-pox. "'This idea he lived to correct ; but the 
prejudices it excited, and the erroneous views to which it gave birth, 
have unhappily been perpetuated. It is ascertained that the horse 
is liable to a vesicular disease of a variolous nature as well as the 
cow, and equally protective. The error consisted in believing that 
this affection was the grease, and that it required to be transmitted 
through the cow to give it efficacy." — But it is now well ascertained 
that the horse, as well as the cow, in different ages and in various 
countries, lias suffered both from the mild and malignant variola'; 
that the latter, when inoculated from the cow, for example, may pro- 
duce an aggravated disease in man ; that the human small-pox can 
be communicated to the cow; and that the matter thus obtained pro- 
duces in man the most perfect form of vaccination. "In other 
words, the direct inoculation of the cow with human small-pox, has 
produced a mild and mitigated disease ; and that such disease, repro- 
duced by inoculation on man, accords entirely, in its character, in its 
progress, and in its protecting influence, with the varola vaccinae as 
described by Dr. Jenner ; thus irresistibly proving his fundamental 
proposition, that cow-pox and small-pox are not bona fide dissimilar, 
but identical; and that the vaccine disease is not the preventive of 
small-pox, but the small-pox itself;— the virulent and contagious 
disease being a malignant variety."* 

Dr. Stephen Brown had early, in this discussion, declared it to be 
his opinion, that the cow-pox is the variola or small-pox of the 
human system; and that it was originally excited in the cow in the 
form of cow-pox, and in the horse in the form of grease, by the direct 
application of smallpox virus to these animals. Such, also, were the 
matured views of Dr. Jenner himself; and they have been remark- 
ably sustained by the recent experiments of Mr. Ceely and others. 

It may be added, as a curious fact in the history of vaccine, that 
various animals, besides the horse and cow, have been vaccinated 
with complete success, as the ass, buffalo, sheep, and even poultry. 

Vaccine matter is, perhaps, most certainly efficacious when taken 
before the tenth day of the eruption; but experience has amply 
proved, that a mature scab is capable of retaining all its virtues for 
many weeks after its separation from the arm. 

Whether we use the fluid matter from the pustule, or the dried 
crust, the best mode of inserting it is on the point of a lancet, about 
the middle of the arm; care being taken to make five or six oblique 
punctures into the cutis vera, without drawing blood. These punc- 
tures should be confined to a very small area, say about two lines in 
diameter. If the dried scab is used, it must be rubbed to a thin 
paste with water, and after its insertion, the spot should be allowed 
to dry without interruption. With these simple precautions, vaccina- 
tion is performed with almost uniform success, and with the following 
appearances : — 

No obvious change is observed until the third day after the in- 
sertion, when a minute inflamed spot is seen. As the inflammation 

* Medico-Chirurg. Review, No. 56. 



[VACCINATION.] 173 

proceeds, a small, circular, flattened and slightly elevated tumour is 
formed. 

About the sixth day, the pustule begins to assume the vesicular 
character, the secretion of matter taking place in the centre, and in- 
creasing until the tenth day, when the perfect vesicle is produced, 
having the following characters: — It is circular or oval, with a dis- 
tinct, smooth, turgid margin, and a depression in the centre: — the 
contained matter being of a uniform pearl colour. 

After the eighth day, the vesicle is surrounded by a bright-red 
areola, varying in diameter from less than an inch to two inches, and. 
accompanied by a radiated tumefaction and hardness of the subjacent 
parts. 

It is at this period of the disease that the febrile and other consti- 
tutional symptoms appear, sometimes very slight, and again in a 
more active form, such as occur in common infantile remittents. It 
is also at this time, as Dr. Gregory remarks, that the child's body is 
covered partially or generally with a papular eruption, which, con- 
tinues for two or three days. 

On or before the twelfth day, the areola begins to decline ; at which 
time the vesicle becomes discoloured, and of a greater firmness, and 
in a (e\v days more is converted into a scab of a dark mahogany 
colour, which becomes blackish as it dries, but retains its smooth, 
surface. This scab separates about the fourteenth day, leaving a 
cicatrix which is circular and slightly depressed, and presents a num- 
ber of minute pits or depressions. The constitutional symptoms are 
usually so slight as to require little or no attention: — they consist in 
a slight fever about the eighth day, with some tumefaction of the ax- 
illa, which pass off with the local affection. A drowsiness, which is 
one of the most common appearances, is often remarked within forty- 
eight hours after the matter has been inserted. 

These are the appearances, and the order in which they occur, in 
unequivocal vaccination. Slight aberrations may take place without 
ning confidence in the result; but there are some deceptive ap- 
pearancea against which it is necessary to provide. These, which 
have been called spurious vaccination are enumerated by Dr. Willan 
as follows: — merely premising that it is not unusual to see a common 
conical pustule, having no character of the vaccine, and of course 
readily distinguished from it. 

" The Jirsi is a single pearl-coloured vesicle, set on a dark-red base, 
llightly elevated. It is larger and more globate than the pustule 
above represented, but much less than the genuine vesicle ; its top is 
flattened, or sometimes a little depressed, but the margin is not 
rounded or prominent. 

M The second appears to be cellular, like the genuine vesicle; but 

is somewhat Bmaller, and more sessile, ami has a sharp amrulated 

edge, The scab is smaller and less regular than that which succeeds 

mum: vesicle; it also falls oil' lunch sooner, and when separated, 

I smaller cicatrix, wlneli is sometimes angltlated, 

u The third irregular appearance is a vesicle without an areola."* 

[• Batrman't Bynop. p. 2UG] 
15» 



174 



[VACCINATION.] 



With respect to the areola, however, it should be remembered, that 
it may have existed without being noticed by the attendants or the 
physician: it may have been trivial in its development, of partial 
duration, and occurring at night, when it would not be noticed. The 
mere asserted absence of the areola, all the other characters being 
perfect, is not conclusive evidence that the disease has been abortive. 

When considerable inflammation ensues, at an early period after 
vaccination, and especially if suppuration takes place, the disease may 
be reasonably suspected. "Now and then" says Dr. Hooper, " it 
happens, that after the spurious pustule, or more properly, the phleg- 
mon, has run its course, which is within a few days, a vesicle begins 
to appear, bearing every characteristic of the genuine vaccine disease, 
and yielding a limpid and efficient virus. In this case the patient is 
as perfectly secured from all danger of the small-pox, as if no fester- 
ng of the puncture had preceded." 

Inflammation and suppuration will occasionally follow a rupture or 
other injury of the vesicle, from which cause its characters are ren- 
dered more or less imperfect and doubtful. In such cases the deve- 
lopment should be assiduously watched ; and if any ambiguity 
remains, the operation should be repeated. 

The characteristics of a genuine vaccine pustule soon become fami- 
liar to the practitioner, and are not easily mistaken. But in doubtful 
cases, the safest plan is to re-insert the vaccine virus in a short period 
after the first operation. 

The causes of spurious vaccination are various; the matter used 
may be itself spurious, or it may have lost its virtue by long keeping. 
But the most common cause of failure is the presence of cutaneous 
disease : and again, there are some children of perfectly healthy con- 
stitutions who are wholly unsusceptible to the vaccine influence. 

It is not to be denied, that the real small-pox has occasionally oc- 
curred in persons who have been, to all appearance, perfectly vacci- 
nated; and the modified disease has been much noticed of latter 
years. But the former is extremely rare ; and the latter, as has been 
elsewhere shown, is so much less severe than the variolous conta- 
gion, as to be a source of little apprehension. 

Amongst a mass of evidence on this subject, I may adduce the 
facts set forth in the Report of the English Vaccine Institution, viz: 
that among several hundred thousand persons who had been vacci- 
nated, no well-attested case of fatal small-pox had occurred : but on 
the contrary, that, when the latter disease did appear, it uniformly 
takes on a mild and manageable form. From these and other facts 
it has been assumed, that the vaccine disease is a perfect security 
against death from the small-pox. 

This axiom in medicine is strikingly supported by the following 
summary, from an authentic report made to the Medical Society of 
Philadelphia. " We may, without the least want of candour, come 
to the conclusion, that only one death from small-pox, after vacci- 
nation, has occurred in Philadelphia during the year 1827, among 
eighty thousand vaccinated persons, and during the prevalence of a 
most malignant and mortal small-pox; while several individuals 
have lost their lives by small-pox, after they had already gone once 



[VACCINATION] 175 

throush the disease. It appears, then, clearly, that vaccination ought 
to lose nothing of the public confidence ; and as a protection from 
the fatal effects of genuine small-pox, it may safely be asserted that 
it is in every sense to be preferred to inoculation."* 

Some authors contend that the protection afforded by vaccination 
does not extend beyond seven, or at most twenty years. In some 
constitutions this appears to be the case; although it may not be so 
general a rule as many suppose. I have repeatedly vaccinated per- 
sons with the most unequivocal success, who had beyond all doubt 
gone through the same process from fifteen to twenty years before. 
In one family I saw five persons, the eldest not more than thirty,, 
all of whom had been vaccinated in the most cautious manner in 
childhood: three of them in succession took the varioloid in a mild, 
form, during which period the remaining two requested to be re-vac- 
cinated, which was done with entire success; the vesicles passed 
through their characteristic stages, and the patients escaped the 
dreaded contagion. Some physicians consider it possible, by repeat- 
ed vaccination, to saturate the system so as to obtain a perfect im- 
munity from any form of small-pox. As a rule, this proposition is 
subject to many exceptions, in proof of which we may cite the fol- 
lowing statement from a recent medical journal : "Whilst sufficient 
facts are wanting in favour of the reputed effects of what is termed 
saturation of the system, to produce a more perfect exemption from 
varioloid, evidences of the insufficiency of such a practice exist, of 
which the occurrences on board one of our public vessels, the North 
Carolina, offer a striking example. In a cruise made by this ship up 
the Mediterranean, she shipped at Norfolk a crew of 900 men, most 
of whom had been vaccinated or had the small-pox ; but were never- 
theless twice vaccinated, prior to the ship's sailing, a third time at 
Gibraltar, and a fourth time at Port Mahon. Dr. Henderson, who 
repeats these facts, states that, notwithstanding this ultra re-vaccina- 
tion, under such various circumstances of virus, climate, &c, 157 of 
the crew had the varioloid. "t 

It is a prevalent opinion, that much of the asserted uncertainty of 
vaccination has originated from a deterioration of the virus in pass- 
ing through a long succession of individuals. Experience, how- 
ever, is adverse to such an hypothesis: and Dr. Thomson observes 
— "that the establishment of such a point, either by experiment or 
observation, would present an anomaly in the history of contagious 
diseases; fori am not aware that any thing analogous to this alleged 
deterioration, has ever been observed to occur in any of the other 
contagious diseases that are capable of being communicated, by con- 
tact or inoculation, from one human being to another. I know, in 
point of fact, that the vaccine virus, which has been used at the Royal 
Dispensary here, and in other parts of Scotland, for a series of is 
i, still continues lo produce, on those who are inoculated with 
it the very same appearances which it produced on the first trials 

[♦ " Report of ili<- Com. of the Philad. Med. Boc. appointed to eollecl facta In rela- 
tion lo toe recent occurrence ol small pox in una ciiy." North Amcr. Med. and 

I 
[r Aincr. Jour. Med. Sci. May, 1836.] 



176 CHICKEN-POX. 

that were made with it; and that these appearances agree exactly 
with those which have been delineated and described by Dr. Jenner 
as characteristic of cow-pox: and I know, also, that the appearances 
of the vaccine vesicle produced by this matter, which must have 
passed through a succession of at least 900 individuals, agree exactly 
with those exhibited by vesicles by inoculation with the more re- 
cent equine matter, with which I have been lately favoured by Dr. 
Jenner."* 

Drs. Mitchell and Bell,t in an able investigation of this subject, 
corroborate the sentiments of Dr. Thomson : and it may be added, 
that vaccine matter, in its most recent state, possesses no more pre- 
ventive efficacy in reference to varioloid, than that which has been 
in use since the discovery of vaccination. 

It would appear that some persons are wholly insusceptible to 
vaccination; the operation may be repeated over and over again, 
without effect. In other cases the susceptibility is restored or 
evolved in a short period of time, and tlie disease goes through all 
its stages in perfection. The inability to take the vaccine, however, 
is no guarantee against small-pox ; for the latter has occurred, in an 
aggravated form, in those persons in whom vaccination could never 
be accomplished: and, moreover, it has been observed, that persons 
in a variolous atmosphere are very insusceptible to the vaccine dis- 
ease.] 



CHICKEN-POX. 



This disease, known also by the name of Varicella, has been often 
confounded with small-pox. Those who maintain the identity of 
the two diseases, and who have figured in the controversy that has 
been so long carried on, have, nevertheless, completely failed in 
proving their position with respect to one point, while they have 
succeeded in another, apparently without being aware of it. Look- 
ing at the diseases symptomatically, there is no doubt a striking dif- 
ference. The symptoms are all much slighter in chicken-pox ; the 
eruption is vesicular, and there are repeated crops ; and further, this 
disease is rarely attended with danger; hut a pathological eye can- 
not fail to discover a marked resemblance. The only questions to 
be determined are the following: Does an attack of the one disease 
prevent the other? Will matter taken from small-pox produce vari- 
cella, or from varicella small-pox? Extensive experience enables 
us to answer both in the negative, and therefore they cannot be 
identified any more than measles or small-pox.J 

[*On Varioloid, p. 320.] 

[t N. Araer. Med. and Surg. Journal, vol. 2. p. 250.] 

_ J Vide Dr. Hennen's papers and experiments, in Ed. M. and S. Journal, vol. 
xiv. p. 409. [Dr. Thomson, of Edinburgh, considers small-pox and chicken-pox to 
be varieties of the same contagion, as will be seen by reference to his elaborate work 
on Varioloid. It appears that Dr. Heberden, a distinguished physician of the last 



MILIARIA— MILIARY FEVER. 177 

["It has been ascertained of the genuine chicken pox, or varicella 
lymphatica, that it occurs only once to the same person; that it 
spreads by contagion; that, nevertheless, it is not communicable by 
inoculation; whereas, the matter of modified small-pox, when en- 
grafted, produces genuine variola; that it occurs equally among those 
who have, and those who have not been vaccinated; that the vaccine 
vesicle and disease proceed with perfect regularity after the occur- 
rence of chicken-pox; and that it affords no protection against small- 
pox, while, on the other hand, small-pox affords no protection against 
it."* 

The pustules in varicella are mostly prominent and rounded; but, 
among a great number, a few will be noticed which are flattened on 
the top. The fluid they contain is at first transparent, becomes gra- 
dually milky, and then straw-coloured. Many of these pustules 
burst spontaneously about the third or fourth day, and form rough, 
dark-coloured scabs, which desquamate without leaving scars.J 

With respect to the treatment of varicella, it is only necessary to 
mention, that it must be conducted in the same manner with other 
slight eruptive fevers; and it should be remembered, that some local 
inflammation may arise, even in the very slightest of them. I have 
known two fatal cases of varicella; one from inflammation of the 
snbstance of i he lungs in an adult, the other from inflammation of 
the membranes of the brain in a child eighteen months old. Since 
the publication of the first edition, I have been reminded of a third 
fetal case which occurred in 1S25, in a child five months old. Traces 
of inflammation were found in the chest and abdomen. The head 
was not examined. 



MILIARIA.— MILIARY FEVER. 

'fins disease is characterized by an irregular eruption of exceed- 
ingly mii.iII round vesicles of the size of millet seeds, and which feels, 
when (he hand is passed over it, as if there were small grains of sand 
beneath the cuticle. Each vesicle is surrounded by a slight inllam- 
inalnrv Mush. 

[It is observed by Dr. Schcdel, that the only disease with which 
miliaria can hi; confounded, is r<zrm<i ; hut in the latter, the vesicles 
an- remarkably confluent, a large number being crowded into a small 
. while in the miliaria they are larger and more isolated.] 

Tins disease i^ said i<» he idiopathic, as well as symptomatic. 
There can be no doubt whatever, that an eruption of this character 
occasionally appears in the course of all fevers and inflammations; 
■Od in such cases, attention ought to he directed to the original dis- 

ccniury, entertained the s.un<- opinion, ami <-;iiis tin- chicken-pox variola puriUai 
box and swine-pox (Varicella globata,) are mere varieties <>i chicken- 
pox, which last lathe varicella ienlicalarls of Wiiian.j 
• [Watsi.n'a Practice ol I'hvic, j, 878 J 



178 ROSEOLA— ROSE-RASH. 

ease. It is also considered one of the diseases of child-bed. Since 
women in that state have been treated in a proper manner, by avoid- 
ing hot stimulating drinks, and by admitting cool air, it is not very 
frequently met with. It is described by authors to commence with 
rigors, sickness, and languor approaching to Syncope, quick pulse, 
heat of skin, and thirst. The eruption does not usually appear till 
four, five or six days after the commencement of the febrile attack. 
Previously to its appearance, there is a sense of pricking, tingling, 
or itching of the skin, sometimes attended with a benumbed state of 
the extremities. The patient is greatly oppressed, and complains of 
a sense of weight about the chest ; the spirits are low, and a profuse 
perspiration takes place, which is frequently remarked to have a 
sour smell. At length the vesicles form into small scales, and fall 
off in a few days. 

The eruption is generally distinct, but sometimes confluent; it is 
said rarely to affect the face, and different crops may appear in the 
same fever; it attacks those most frequently, who have been pre- 
viously weakened by disease, fatigue, or long-continued sweating or 
who have had a hot regimen. The miliary vesicles often occur 
during the course of many of the puerperal diseases, such as milk 
fever, inflammation of the brain and peritoneum. 

Mr. Burns, in his Principles of Midwifery, p. 420, says, " Whether 
the miliary fever be idiopathic or symptomatic, the treatment is the 
same." If he mean to state, that slight miliary eruption is to be 
treated in the same manner as miliary eruption "depending (to use 
his own expressions,) on fevers connected with a morbid state of the 
peritoneum or brain, which generally prove fatal," I cannot concur 
with him, as the eruption is to be regarded only as an accidental 
symptom of another disease. 

Treatment. — If this disease occur in the course of inflammation of 
the peritoneum, brain, &c, the particular disease ought to be treated 
in the proper manner, without reference to the eruption. If not, the 
bowels are to be regularly attended to, sweating is to be avoided, as 
well as every thing which heats the patient ; and indigestible food 
must be prohibited. Whenever the patient is found perspiring, the 
linen should be changed in a careful manner, and the body properly 
dried and rubbed with a soft towel ; in this case, sulphuric acid will 
be found very useful, and there can be no objection to the moderate 
use of wine and bitters. 



ROSEOLA.— ROSE-RASH. 

Roseola is a fever attended by a rose-coloured efflorescence, 
without wheals or papulae ; [but sometimes in blotches of a quarter 
of an inch or more in diameter, which continue from one to two, 
three, or even four days. It is a common disease of infancy, and 
more particularly in the summer season, when the itching of the 



URTICARIA— NETTLE-RASH. 179 

skin renders it very irritating. Also the eruption assumes a ring-like 
form, sometimes a consecutive, but followed by little or no des- 
quamation,] and apparently not contagious. It has often been 
confounded with measles and scarlet fever, and I have seen the 
wisest heads baffled in determining the point; in one case in which 
such a division of opinion took place between two physicians, a 
third declared that the patient laboured under small-pox, and the 
result of the case proved that his opinion was correct. 

This is a disease which may very frequently be traced to indi- 
gestible matter, and particularly fruit, in the stomach and bowels; 
therefore the treatment is very simple; so simple, that even in the 
higher ranks, medical men are seldom consulted ; and they would 
probably be still less frequently called, only that parents are afraid 
that it is scarlet fever. Confinement, attention to the bowels, and 
avoiding solid animal food for a few days, are the best means which 
can be adopted. 

Willan and Bateman have given an account of seven varieties of 
this disease, but no practical benefit can be derived from such minute 
hair-br 
drawn. 



URTICARIA.— NETTLE-RASH. 

This disease is known to the vulgar by the name of nettle-rash, 
and is distinguished from other febrile eruptions, by circular eleva- 
tions of the cuticle, of a red colour, with a white spot in the centre, 
and is usually termed a wheal; [these wheals, however, are often 
very irregular, of a mottled character, either whiter or redder than 
the surrounding skin;] and here, again, Willan and Bateman have 
unnecessarily described six varieties. 

The eruption is generally preceded by marks the most distinct of 
gastro-intestinal irritation and fever; and the patient is affected with 
restlessness, oppression, languor, and want of appetite ; his tongue, 
however foul, will in general be found red at the tip, and round the 
edges. If the eruption be very general, the patient suffers much 
distress from the heat and itching of the parts, but the internal disor- 
der will be found to be relieved. Sometimes the rash appears only 
when tin; individual is heated by exercise, or by wine, or when he is 
Dtidressing himself; and it is also frequently excited in a fresh part, by 
friction or .scratching. This is an affection which is often produced 
by eating particular articles of food, [especially, as Dr. Willan has 
remarked, by shell fish, lobsters, crabs, shrimps, and the common 
myiilus or sea muscle. « In a few individuals, " he adds, u in con- 
■equence of a peculiar idiosyncrasy, other substances when eaten, aro 

• Ii affords me great pleasure to refer to Mr. Ptambe's Practical Treatise on Dis- 
>t the skin. That gentleman has taken correct views pf the subject, and treats 
of all the affection! pathologically; therefore he has few subdivisions. Ii is the best 
work v o ihc subject. 



180 URTICARIA— NETTLE-RASH, 

followed by the same immediate affection of the skin ; such as mush- 
rooms, honey, oatmeal, almonds, and the kernels of stone fruit, straw- 
berries, &c. In some persons the internal use of valerian has produced 
the nettle-rash. The operation of these substances is almost instanta- 
neous, and the symptoms are extremly violent for several hours."* 

Sometimes nettle-rash is attended by the sensation of needles or 
other sharp points penetrating the skin ; these pains, which are at 
first limited to a spot or to a limb, extend to other parts, and cause 
extreme suffering and sometimes even severe cramps. The eruption is 
variable, and sometimes altogether absept in this form of the disease.] 

It appears to me, that individuals who are frequently subject to 
this affection, and others of a smilar nature, during youth, are those 
who, in after-life, are liable to be affected with gout. 

It is sometimes difficult to distinguish urticaria from another very 
painful and troublesome affection, which is known by the name of 
erythema fugax; but this is a matter of no practical importance, as 
botli eruptions are produced by the same causes, and cured by similar 
remedies. 

Urticaria may continue for an indefinite period, and maybe repro- 
duced in particular constitutions every time the stomach is disordered. 

Treatment. — Nothing is more simple than the management of a 
case of urticaria; but much more depends upon the patient himself 
than upon the remedies which a physician may prescribe. The pa- 
tient must find out by experience, the articles of food which disagree 
with him, and he must have sufficient resolution to avoid them lor a 
time. It should be impressed upon young practitioners, that danger 
sometimes proceeds from the repulsion of the eruption by cosmetics. 

A very beautiful young lady was frequently troubled with febrile 
symptoms and this rash. She was attended by an eminent physician 
who gave her a large bottle of a strong solution of sugar of lead, with 
directions to sponge her body with the wash when her skin was very 
itchy. Upon the first occasion, she stripped herself, and applied it as 
extensively as she could, and it surprised her that the itching sud- 
denly ceased; upon examination, the eruption, which was very vivid 
before, had now almost entirely disappeared. She instantly felt sick, 
oppressed, and fainted; and continued for such a considerable time in a 
state of insensibility, that her attendants were doubtful other recovery. 
She survived, but has not since known what it is to enjoy a day's 
health. 

[A case also came under my own care, iti which the eruption, from 
causes unknown, receded early in the disease; it was almost immedi- 
ately followed by an aphthous condition of the month and consequent 
ulceration of the tongue, which continued with much suffering and 
constitutional irritation for upwards of two months, and was seem- 
ingly cured by change of climate.] 

Besides avoiding every thing that disagrees with a patient, it may 
be mentioned that gentle laxatives are essential remedies; and that 
an emetic is highly useful, if an indigestible matter be still in the 
stomach. 

[* Synopsis, p. 87.] 



PESTIS— THE PLAGUE. 181 

[I have found the use of small and repeated doses of magnesia to 
be particularly beneficial in urticaria; and this, with a farinaceous 
diet and the avoidance of acids, will, in general, meet all the indica- 
tions. The safest external applications are warm or tepid bathing, 
either with simple water, or whiskey and water mixed half and 
half. When the itching is local and very irritating, the application 
of laudanum affords great relief. I have known this disease to last 
with severity for several days, and to require free bleeding before the 
distress became in any degree tolerable.] 



PESTIS.— THE PLAGUE. 

The disease, which is now to be shortly described, appears to be an 
endemic fever, attended during its course by buboes, carbuncles, or 
some eruption on the surface of the body. It appears to be, under 
certain circumstances and seasons, highly contagious; and it would 
seem, also, to be occasionally epidemic. 

The accounts we have of the phenomena of this disease are so 
contradictory, and the histories of morbid appearances are so few and 
meagre, that I have not sufficient data before me wherewith to form 
pathological descriptions. 

The plague, it would appear, is sometimes very mild, at others 
very severe; and if it be a fever, of which I have no doubt,* the 
symptoms must not only vary in intensity, but they also must have a 
very wide range of character. The disease must have varieties and 
shades arising out of one organ being more severely affected than 
another, as well as from local congestions and inflammations. It 
appears to be modified, also, by season, situation, and habits of in- 
dividuals. It is not to be wondered at, therefore, that different writers 
should have given different histories of the symptoms and progress 
of this disease ; but, as yet, we have no pathological description that 
can be depended on; therefore my observations must be brief. 

:ns to be the opinion <>l some physicians, that the plague is 
nothing more; than B malignant typhus, and the only peculiar symp- 
tom that has been described is the bubo, carbuncle, or the appearance 
(.1 some eruption on the surface of the body; and all writers agree in 
opinion, thai the safety of the patient very much depends upon the 
suppuration going on speedily and kindly. The plague, therefore, 
seems to be closely allied to the exanthemata, and more particularly 
to small-pox. 

The disease appears to be ushered in by rigors and oppression, 

followed by beat of skm, great prostration of strength, giddiness, and 

headache; the expression of the countenance is besotted, and the 

have a muddy, glistening appearance. It is stated, however, 

that m some cases there is B ferocious aspect; in others, the patient's 

• I have bad ths pleasure of enjoying everal communications srith l>r. M< fofTnc, 
who resided many yeai in Turkey, and who has had ample opportaDtUas cd 
ihcfli i lion, thai the p] er attended by hoboes, 4k 

16 



18 THE PLAGUE. 

look is subdued. The pulse varies much; it is sometimes quick and 
full, at others, quick and small; sometimes described as being hard, 
at others soft. The intellect is sometimes clouded ; at others, there 
are insensibility and fierce delirium ; occasionally stupor takes place, 
and in some cases the functions of the brain remain distinct and clear. 
The patient, in general, seems indifferent respecting his fate ; the 
tongue is at first moist, although it may be more or less loaded; there 
is sometimes constipation, at others diarrhoea; the stools are always 
highly offensive; the stomach is in general very irritable, every thing 
taken being almost instantly rejected. 

In a few days from the first attack, generally the third, pains, often 
acute, are complained of in the groins and arm-pits; and, unless the 
swelling and suppuration of the glands go on quickly, death soon 
takes place. Sometimes carbuncles appear, with or without the 
buboes; but petechia? more frequently than carbuncles. Discharges 
of blood from the stomach and intestines often take place in the last 
stage. Sometimes the disease is very rapid in its progress, running 
through its course in thirty hours. It is said, that if the patient sur- 
vive the fifth day, the bubo being completely formed, he may be 
pronounced to be doing well, if not actually out of danger. As in 
the acute eruptive diseases, there are two periods fraught with 
greater danger than others, viz., that at which the bubo makes, or 
ought to make, its appearance, and that at which it ought to be 
matured. 

The convalescence, as in all severe fevers, is very slow, which is 
attributed to the extremely debilitated state in which the patient is 
left; but there can be little doubt that a great deal is generally owing 
to bad nursing, and want, perhaps, of sufficient comforts. 

It is a curious and interesting fact, that Sir James M'Grigor and 
Sir John Webb, the former the director-general of the medical depart- 
ment of the army, the latter director-general of the medical depart- 
ment of the ordnance, should have distinguished themselves in the 
same field of investigation, having been both employed with our 
Egyptian army above thirty years ago, when they displayed that 
talent, zeal, and humanity in the performance of their duties, which 
endeared them to all who were placed under their care. It was 
there these distinguished persons gave evidence of the great powers 
of mind and regular habits of business, which marked them out as 
men admirably qualified for the high situations in which they have 
been subsequently placed, and which they have filled with so much 
honour to themselves, and benefit to the service. Their statements 
respecting the plague, will be read with much interest and advan- 
tage.* 

Treatment. — Sydenham recommended free and repeated vene- 
section in this disease, during what may be called the eruptive fever, 
and it has occasionally been practised since his time: but even Syden- 
ham himself seemed latterly to prefer sweating the patient, under the 
idea of withdrawing the pestilence in that way from the body, which 
weakened him less than blood-letting. Some individuals condemn 

* Sir James M'Grigor's Medical Sketches of the Expedition from India to Egypt. 
— Sir John Webb's Narrative, 6th vol. Medical Transactions. 



THE PLAGUE. 183 

bleeding entirely. The same difference exists with regard to purg- 
ing. Cullen condemns both, upon theory, but recommends the vio- 
lence of reaction to be moderated, as far as it can be done, "by 
taking off the spasm of the extreme vessels." The application of 
oil to the surface of the body is believed to be a preservative, and it 
has also been employed to cure the disease; but even upon these 
points, such opposite statements have been promulgated, that we 
have no means of forming correct opinions. A great number of 
other remedies have been strongly recommended — as mercury, wine 
and bark, opium and aether, emetics, diaphoretics, and the cold affu- 
sion ; and, if my notions of the disease be at all correct, there are 
cases and stages in which several of these remedies, if not all of them, 
may prove highly beneficial; but there are others in which they must 
have the opposite effect. For example, if there be violent inflam- 
mation and congestion of the brain, no one will say that wine, aether, 
bark, or camphor, are the proper remedies; but in which cold appli- 
cations to the head, and the action of mercury, might be beneficial. 
In the last stage of the disease, the lancet would be most improper, 
when wine, xMlicr, opium, and even brandy itself, may snatch the 
person from the grave. If the stomach be irritable, which it almost 
always is in this disease, no one, I hope, would think of making it 
more so by exhibiting emetics and large doses of bark. It is to be 
feared that the recommendation and condemnation of various im- 
portant remedies have taken place, without reference to the stage of 
the disease, the particular organ or organs affected, the peculiarities 
of the prevailing distemper, as well as the idiosyncrasy of the patient; 
but it becomes me to speak with diffidence upon a suhjeci respecting 
which I must acknowledge myself to be profoundly ignorant. 

The reader who wishes for more minute information, must peruse 
the various works published on this subject; or a most excellent ab- 
stract of Ihem, in the third volume of Dr. Mason Good's Siudy of 
Medicine. The chapter on the plague appears to me to be the most 
meritorious j >:i r t of Ins work. 

[ riii- Following interesting particulars, respecting the plague in 
pt, are from the celebrated Clot Bey, in a letter to Dr. Chevrin, of 
Marseilles, dated Cairo, March 36, L835. 

Tin: plague Commenced in Alexandria, in November; for a month 
it w.is very fatal, and, altogether, 20,000 persons have died It be- 
gan in Cairo, in December, but, during the last fortnight only, has 
been of .1 BerioUl typo. The first symptoms are pain in the head, 
iiausi:i and vomiting, injected eyes, staggering walk, as if from 
drunkenness, stupid expression, white moist tongue, full and frequent 
pulse. At tins [period, emetics and diffusible stimuli may be tried, 
but dot Bey knows nothing of their effect. On tin' Becond or third 
day, there is mental confusion, sometimes delirium; the tongue is 
dry in the centre, with red edges'; the skin hot; there is often pain 
in the epigastrium; rarely diarrhoa ; buboes and carbuncles. There 
is now actually irritation in the digestive canal, brain, and lymphatic 
glands; .Hid bleeding aud cupping are employed, with cauterization 
to the buboes and carbuncles, to fix the irritation in the skin <>n the 
fifth and sixth days, petechia and blue patches on the Bkin. Kevul- 



184 THE PLAGUE. 

sives to the extremities. This treatment has apparently saved some 
patients. The corpses have not the hideous aspect which physicians 
have described and artists painted. The petechia are particularly 
on the neck, sides of the chest and limbs; the buboes in the groins 
and armpits; very rarely in the neck: all the lymphatic glands were 
enlarged in those who had no buboes ; carbuncles in three cases 
only. No particular tendency to rapid decomposition; subcutane- 
ous veins not apparent. Heart, and veins in the cavities, gorged 
with black blood, as well as the liver and spleen ; this viscus was 
generally found doubled in size and softened. Arteries empty; kid- 
neys of a deep violet, gorged with blood, haemorrhage in their pelves. 
The stomach always contained a blackish fluid ; its mucous mem- 
brane, much injected, exhibited red patches like petechias, which, 
sometimes, from the size, might be called ecchymoses; their last 
degree is ulceration. The intestines were in a similar condition, but 
less well marked : the lymphatic glands were always engorged, 
sometimes increased five or six times, softened, and of a colour like 
lees of wine, and sometimes black. Those of the groin, or armpit, 
by their agglomeration, formed a homogeneous mass of a colour 
almost always like lees of wine, with effusion of black blood into 
the surrounding cellular tissue. A similar change was seen in the 
chain of glands along the vessels of the abdomen and chest; and, in 
many cases, the extravasation of blood around them amounted to 
haemorrhage. Sub-arachnoid veins and the sinuses gorged; paren- 
chyma of the brain and spinal marrow natural, except in two or three 
cases, where it was softened.*] 

[* From the British and Foreign Medical Review, No. 1.] 



PART II 



DI8EA8E8 OF THE ORGANS CONNECTED WITH THE DIGESTIVE 
SYSTEM. 



16* 



CHAPTER I. 



DIFFICULT DENTITION. 

Few children go through the process of dentition without some 
suffering; and, when teething is difficult, many complaints arise, 
which fall under the denomination of infantile diseases. These are, 
fever, determinations to the head, occasioning inflammation of the 
brain and its membranes, or convulsions, cough, and difficulty of 
breathing; bowel complaints; cutaneous and glandular affections; 
inflammation of the eyes, and sores behind the ears. 

Authors have long remarked, that children who teethe at an early 
period, have least suffering ; and the same observation has been made 
with respect to those who have a considerable flow of saliva. There 
have been instances of children born with teeth, which happened, it 
is said, to Richard III, and Louis XIV; and Haller has cited a con- 
siderable number of similar cases. 

Some infants cut the first pair of teeth by the end of the third 
month; in other instances, not until they are sixteen or eighteen 
months old. In general, however, they are cut between the sixth 
and eighth month. The two centre incisors of the lower jaw com- 
monly appear first; in the course of a month, their opponents in the 
upper jaw protrude; after this the two lateral incisors of the lower, 
and then those of the upper jaw, appear. Between the twelfth and 
sixteenth month, the anterior grinders of the lower, and then those of 
the upper jaw are cut; subsequently, the cuspidati,or eye-teeth, pro- 
tni'li:, and after these the posterior grinders; so that children usually 
have the first set of teeth (twenty in number) complete, by the time 
they have attained the age of two years, or two and a half. There 
are generally intervals of several weeks between the cutting of each 
pair. 

The formation of each tooth goes on in a membranous and vas- 
cular sac, which is firmly united to the gum; and, if we attempt to 
tear the gum from the jaw, the sac is brought along with it. This 
■ac, it would appear, subsequently becomes absorbed ; but when it 
is thicker than usual, more vascular, and long of being absorbed, it is 
one of the alleged causes of difficult dentition. The irritation pro- 
duced by the pressure of each tooth against the gum, in its advance- 
ment to the surface, particularly when the child teethes late, and the 
gums are bard and cartilaginous, also occasions the differeut phe- 
nomena which are ranked under the same appellation. 

A child, in such circumstances, is observed in be restless, fretful, 

and feverish; to sleep little, and is often seized with sudden tits of 

Minn-. The bowel i are out of order, and the evacuations fetid. 

On some occasions, marks of determination of blood towards the 

head take place, viz., great restlessness, flushed face, sudden fits of 



188 DIFFICULT DENTITION. 

crying, apparent suffering when brought into the erect posture, start- 
ings, slight spasmodic movements of the muscles of the face, and 
even general convulsions. 

Many children, whenever they cut a tooth, are teased with a 
cough, depending on bronchitic irritation or inflammation. This is 
announced by wheezing. Others suffer from constipation, while 
many are afflicted with troublesome diarrhoea. 

Cutaneous and glandular affections are often observed during 
difficult dentition. The glands of the neck, and the submaxillary, 
are those generally affected, and they sometimes suppurate. Of the 
eruptions, the porrigo larvalis, and lichen, are those most commonly 
seen. 

Occasionally there is inflammation of the eyes, particularly those 
forms which are termed ophthalmia purulenta and ophthalmia tarsi; 
and sores take place behind the ears, which seem to operate bene- 
ficially. This statement will show the propriety of examining the 
mouth, when we are called to a child labouring under these or any 
other affections during the period of dentition ; when the mouth may 
feel very hot, and on examining the gum over the tooth which we 
suspect, it will be found to be elevated, very red, sometimes white 
and shining; the ridge or seam, which runs along the jaw in the 
direction of the teeth, will, in general, be found to have disappeared. 
If such appearances present themselves, the tooth may be pronounced 
to be far advanced ; at all events, it is well to be able to say whether 
it be near at hand or not, as mothers are often disappointed if the 
tooth over which the gum is cut, does not show itself in a day or 
two ; whereas, if they are previously told that it is not so near, they 
will, in general, be satisfied. The best remedy is to divide the gum, 
down to the very tooth, by crucial incisions. Many people entertain 
a dislike to this operation, from the idea that the gum is hardened by 
the cicatrix; but they may be safely assured that this is not the case, 
and that the tooth will be advanced, certainly not retarded, by the 
scarification. If the operation be effectually performed, it constitutes 
the principal part of the treatment. Should the gum even heal imme- 
diately, the bleeding will remove the local inflammation, upon which 
the febrile symptoms frequently subside. The bowels must be kept 
freely open, and the tepid bath is often of great service. If the face 
be flushed, with other marks of determination to the head, the appli- 
cation of cold may be tried ; the child should at least sleep without 
its cap, and use a hard pillow ; frequently have I seen it advantageous 
to change a down pillow for one filled with fine- shavings. It is 
probable that some of the serious affections of the brain to which 
children are liable, may be attributed to warm caps and soft pillows. 
The bowels must be more freely acted upon; and if these means do 
not succeed, it will be well to apply leeches to the feet, which may 
be subsequently placed in warm water, for the purpose of en- 
couraging the bleeding ; besides which, the haemorrhage is better 
under command upon the application of a bandage. Many prac- 
titioners are heard to complain of the great difficulty in stopping the 
bleeding in young children, but I never experienced any impediment. 
In theirs* place, we ought always to point out the situation where 



DIFFICULT DENTITION. 189 

the leeches ought to be placed, which I take care shall be, if possible, 
over a bone, against which pressure can be applied. Secondly, not 
to apply too many at a time. It is rare to find more than one orifice 
troublesome, from which the bleeding will be easily suppressed, by 
gently pinching the skin between the finger and thumb for a few 
minutes. I have never been obliged to use the actual cautery, or 
even caustic. 

We are often not called, however, till convulsions have actually 
taken place, which are to be treated in the manner to be subsequently 
described in the second volume. I may, however, mention here, 
that the child should be put into a warm bath as soon as possible ; 
the face sprinkled with cold water; and, if a fit should continue long, 
and threaten danger, a vein should be opened on the instant. Should 
the external jugular be readily observed, blood may be drawn from 
it ; but if a vein cannot be found, the hot bath and stimulating fric- 
tions must be trusted to till leeches are obtained. Great attention 
should be paid to keep up a brisk action in the bowels, by means of 
suitable doses of calomel and jalap, or calomel combined with rhu- 
barb or scammony, together with castor or croton oil and injections; 
but all these means will be of no avail unless the gums be freely 
scarified. 

Couyh is occasionally a troublesome attendant on teething, and 
practitioners will be found, in general, to act empirically, unless they 
are able to ascertain whether it depends upon any diseased action in 
the lungs, or merely upon irritation about the epiglottis and pharynx. 
If (he latter, a common cough mixture may do good ; but it will be 
inefficacious, perhaps injurious, if the cough proceed from bronchitis, 
which may sometimes require the application of leeches or of a blis- 
ter, or contra-irritation produced by a mustard plaster, or the oint- 
ment of tartar emetic. If the lungs be very much loaded with 
mucus, which is easily ascertained, an emetic will be very servicea- 
ble ; but the treatment of bronchitis need not be dwelt upon in this 
place. It is only necessary to state the general principles, with re{e- 
10 the affection now under consideration. 

When B child, who is suffering from difficult dentition, has diarrhoea, 
we should not be in a hurry to check it, particularly if there be 
marks of determination to the head. The bowel complaints of chil- 
dren are of so much importance, that it is necessary to treat of them 
in a separate article, with a view to point out their pathology; but 
it must lie mentioned in this place, that the best practice is to exhibit 
a little castor oil in the first instance ; and if there be any pain in the 
abdomen, warm fomentations are to be used ; should there still be 
signs of Buffering, a leech or two may ho applied, followed by very 
Btnall doses o! Dover's powder or a drop or two of Hatlley's sedative 
solution of opium. 

It is verv fortunate that children, upon (lit; occurrence of the most 
tritluiL' febrile symptoms or disorder of the bowels, are liable to erup- 
tions on the surface, because they act beneficially by removing irri- 
tation and increased action, on many occasions inflammation itself, 
from internal organ*. When these eruptions take place during the 
course of dentition, it will almost always be found best not to meddle 



190 DIFFICULT DENTITION. 

farther with them than to enjoin cleanliness; indeed, on many occa 
sions, do what we will, the eruption continues, the child becoming 
better between the periods of cutting teeth. I have frequently seen 
great mischief done when external applications had the effect of re- 
pelling the eruption, and, on more than one occasion, death itself. In 
"porrigo larvalis," when there are great heat, itching and inflam- 
mation of the part, I have found it answer well to apply leeches to the 
inflamed surface, and to cover the part with oiled silk. The child's 
hands should be muffled, to prevent the face from being scratched 
and disfigured. 

Glandular affections may be safely let alone, unless they become 
inflamed and painful, when the practitioner will do well to apply 
either leeches, fomentations, or a soft warm poultice. If matter 
form, the sooner it islet out the better, in whatever constitution it 
may occur, there being far more danger of leaving a disagreeable 
mark, by allowing the pus to discharge itself, spontaneously, than by 
using the lancet. 

We are often consulted respecting inflammation of the eyes at this 
period of life. Generally speaking, the disease will be found to be 
confined to the conjunctiva ; sometimes to the tarsi ; there is rarely 
deep-seated inflammation on the eye itself. A leech or two applied 
to the temple, is always safe practice, as well as a blister behind the 
ear; indeed, nature points this out, by the relief which supervenes 
upon a natural sore appearing in that situation. Let me add, that 
whenever we have occasion to blister a child, we should be careful 
that none of the powder of cantharides is sprinkled upon the surface 
of the plaster, which frequently creates unnecessary irritation ; and, 
above all, the blistered surface should be carefully examined every 
day by the medical attendant, till it shows a healing tendency, as it 
is apt to slough, which the timely application of a linseed poultice 
will very frequently check. With respect to the natural ulcerations 
that take place behind the ears, it is only necessary to use frequent 
ablution with warm milk and water, and to take care that they are 
not unnecessarily irritated. Great uneasiness is often produced by 
carelessly removing the dressing; this might always be avoided by 
previously applying tepid fomentations. An occasional opiate is 
very beneficial ; but no medicine of this kind should be left in the 
way of an ordinary nurse, who will often administer it to secure to 
herself a quiet night to the great injury of the child; even Dalby's 
carminative, or syrup of poppies, should' never be left in the nursery. 
I have known many children destroyed by their constant exhibition. 
The American soothing syrup is another remedy that is, perhaps, too 
frequently ordered by medical men : it is supposed to soften the 
gums, and to render the process of teething easier; which it does, 
not by mollifying the gums, but by virtue of a narcotic principle 
which it contains. 

A child, when teething, carries every thing to its mouth, bites it, 
and thereby seems to experience relief, and nothing will be found to 
please it more than rubbing the gums with the finger. A gum-stick 
promotes the flow of saliva, and amuses the infant. 



[PAROTITIS.] 191 



[PAROTITIS.— MUMPS.] 

[Cynanche parotidea. — This disease is an inflammation of the pa- 
rotid gland, appearing on one or both sides at the same time. It is 
most common in boys before the age of puberty, and is seldom seen 
after twenty years of age. It follows the law of contagion in attack- 
ing the same individual but once, and also in affecting several or 
sometimes all the children of the same family successively. 

The symptoms are rigors, fever, pain and tumefaction of the paro- 
tid and adjacent glands, with some soreness of the throat, and conse- 
quent difficulty in opening the mouth and moving the jaws. Although 
the distress is often great for three or four days, there is seldom any 
danger. I have never seen the inflammation terminate in suppura- 
tion; yet this has occasionally happened. One of the most serious 
attendants on mumps is metastasis to the testicle in the male sex, 
and to the breasts in females. In both cases the glands swell and 
become, in other respects, highly inflamed; but in the extensive expe- 
rience of the late Dr. Dewees, prolonged as it was through a period 
of forty-five years, that gentleman informs us that he had never seen 
any permanent evil follow these translations. 

In the treatment of mumps, nothing more is requisite, in ordinary 
cases, than rest, mild cathartics and a light diet, conjoined with occa- 
sional spirituous or volatile fomentations to the affected parts. In 
severe cases, however, free leeching is demanded, to be followed by 
a blister behind the ears with the ordinary treatment of febrile dis- 
eases. 

The parotid gland is also liable to inflammation of the common 
phlegmonous kind ; and this, when it is aggravated by neglect or 
'j.vpusure, sometimes takes on the process of suppuration in a very 
slow and painful manner; but the treatment will be inferred, from 
what has already been said of other local inflammations.] 



CHAPTER II. 



DIFFICULT DEGLUTITION FROM INFLAMMATION, ULCERATION, OR 

ENLARGEMENT OF THE TONGUE; CYNANCHE TONSILLARIS; 

CYNANCHE PHARYNGEA; INFLAMMATION OR 

ULCERATION OF THE (ESOPHAGUS. 



DIFFICULT DEGLUTITION/ 

Difficult deglutition may be produced by inflammation, ulcera- 
tion, and enlargement of the tongue, which are often caused by the ac- 
tion of mercury and other metallic poisons, and still more frequently 
by disease of the digestive organs. If the affection be produced by 
mercury, leeches applied to the cheeks are said to be very useful, as 
also a wash composed of a solution of the chlorate of soda, or that of 
lime. Several serious cases of inflammation of the tongue have 
lately been published. Two will be found in the 92d and 93d Nos. 
of the Edinburgh Journal, and a fatal one in the 214th No. of the 
Lancet. I am inclined to believe that inflammation and enlargement 
of the tongue are generally owing to some temporary diseased action 
in the chylo-poietic viscera. The experience of any professional man 
may be appealed to, who is liable to derangements of the stomach 
and bowels, whether he has not, on such occasions, felt his tongue 
sometimes swollen and painful, and even slightly ulcerated in different 
parts of the tip and edges; and whether he has not been led to attri- 
bute such a condition to a morbid state of his digestive organs? 
Whether this view be correct to the full extent or not, the stomach 
and bowels must be attended to in the treatment. 

Children, in particular, are very liable to white specks, vesicles, or 
ulcerations on the tongue, and over the whole mucous membrane of 
the mouth and fauces. These specks are called aphthse, (stomatitis). 
We meet with this affection in two forms, one of which is mild, the 
other very severe. In the first, the treatment consists in keeping the 
bowels gently open, avoiding solid food, and using the warm bath. 
In the last, I feel persuaded, from the vomiting, griping, and purging, 
and the intensity of the other symptoms, that the disease affects con- 
siderable portions of the intestinal tube, and requires a different plan. 
Before the appearance of the ulcerations in the mouth, the constitu- 
tional symptoms occasionally run high, which are sometimes relieved 
upon the mouth becoming sore; so that this affection has some 
resemblance to the exanthemata. Mr. Burns, in describing this dis- 
ease, states, that " the child is sometimes drowsy, and oppressed for 



DIFFICULT DEGLUTITION. 193 

some hours, or even a day or two, before the spots appear, and oc- 
casionally is affected with spasms. The fever and oppression are 
often mitigated on the appearance of the aphthx." Children 
affected in this manner, suffer great pain, and are consequently ex- 
ceedingly peevish. The stools are generally acrid, sour, and disco- 
loured ; there are often tenesmus, and prolapsus ani, the surface 
around the anus being excoriated. Successive crops of aphthae ap- 
pear, which resemble small portions of curdled milk adhering to 
different parts of the tongue and mouth; after a time they become 
yellow, and seem to slough off, but may be renewed many times. 
When they drop off, the parts below frequently look raw, particularly 
in severe cases, in which the crust sometimes becomes dry and hard; 
occasionally the parts look very foul, dark-coloured, and have a fetid 
smell. A case of an adult lately fell under my observation, in which 
great suffering was produced; the sloughs were most extensive, and 
portions even of the palate itself were thrown off. 

The diseased action frequently extends into the air passages, an- 
nounced by dyspnoea and cough. Children brought up by the spoon, 
are more liable to aphthous affections than others, as well as those 
whose bowels are neglected, and are insufficiently clothed. 

Treatment. — The above pathological description of the disease, 
leads at once to the proper mode of practice. In the two cases of 
inflammation of the tongue recorded in the Edinburgh Medical and 
Surgical Journal, venesection and the application of leeches produced 
temporary benefit only, while deep scarifications were had recourse 
to with permanent advantage. It is probable, however, that suffi- 
cient attention has not been always paid in similar cases to the con- 
dition of the stomach and bowels. 

With respect to the severe cases of aphthous affections of the tongue 
and mouth, I can speak strongly of the advantages derived from the 
frequent application of leeches to the abdomen, if the strength be 
: thu warm bath, and contra-irritation on the abdomen by means 
of a stimulating embrocation, or the tartar-emetic ointment. The 
contents Of the bowels should be discharged by an occasional dose of 
castor oil, or a few grains of rhubarb. An injection, composed of a 
of laudanum, and a tablespoonful of starch or gruel, may 
be thrown into the rectum, by means of a small penis syringe ; but 
it is difficult at all times to make a child retain it. Dover's powder, 
united with aromatic powder, is also a good remedy. 

hild upon tin; breast be affected in this manner, no other food 

lid be allowed; if it be already weaned, ass's milk ought to be 

provided, but if that cannot be procured, whey, mixed with a little 

m, and occasionally ;i little thin gruel, may be. substituted ; beef 

ind soups of all kinds, are, according to my own experience, 

fad, until tip: disease be fai upon the decline ; if the child's strength 

inking, wine, properly diluted, is far less exceptionable than 

«>r animal jellies. A weak solution of the chlorate of sod.-:, 

combined with an opiate, will be found serviceable, a teaspoonful 

tor a doSJB, Considerable mischief is sometimes done, ami children 
are verv much and unnecessarily fretted, by the application of borax 
17 



194 [GANGRENE OF THE MOUTH.] 

and sugar introduced into the mouth upon a cloth, or a finger, and 
rubbed so as to remove the crusts. 

[I never saw a case of aphthous mouth in children, that was not 
accompanied by acidity of the stomach ; and I have derived great 
advantage from the frequent use of small doses of calcined magnesia. 
This may be applied dry to the tongue, or it may be prepared as 
follows: with a small teacupful of water, mix a heaped teaspoonful 
of magnesia ; of which a teaspoonful should be given every hour, 
first stirring the mixture, which may be sweetened if desirable. For 
the same purpose I am in the practice of giving a mild solution of 
of the bi-carbonate of soda. 

In children, there is great difficulty in applying local remedies with 
sufficient frequency to render them available. The best of these is 
a solution of nitrate of silver, four grains to the ounce of water, and 
applied with a camel's hair brush. Diluted tincture of myrrh, and 
an infusion of white oak bark, gum catechu or common green tea, 
all answer extremely well as a wash for the mouth.] 



[GANGRENE OF THE MOUTH.] 

[We propose, in this place, briefly to notice a painful and not 
unfrequently fatal disease, which has occasionally appeared in our 
larger cities, and known by the name of gangrene of the mouth, 
water canker, cancrum oris, &c. 

This remarkable affection is not the termination of ordinary inflam- 
mation, but often comes on without pain, heat or redness, yet with 
a hard swelling in one or both cheeks, with so little tenderness, that 
"the patient seems all but unconscious of it; and but for the enlarge- 
ment being obvious to the eye, the mischief would probably escape 
notice altogether in its early stage. Indeed, as it is, the tumefaction 
is occasionally mistaken for affections of a much less serious descrip- 
tion. The skin of the cheek has a peculiar glossy or waxy ap- 
pearance. On examination of the mouth, we detect a whitish or 
ash-coloured eschar, without any inflammatory redness of the sur- 
rounding membrane; generally in the centre of the cheek or in the 
commissure of this part and the lower jaw. The gums look pale 
and spongy. There may be a certain degree of languor, dulness or 
slight feverishness, but not less frequently there is nothing to call 
particular attention to the general health. Such are the principal 
phenomena of the first stage of the disease. As it advances, the 
slough spreads rapidly over the interior of the cheek and lip, and 
invades the gums. Saliva escapes in great quantity, at first clear, 
afterwards mixed with dirty sanious matter, which has a horrible 
fetor. About the same time the outside of the cheek presents 
a pale, ashy spot, which soon becomes livid, and sphacelates. The 
extension of the disease to the bony structure is evidenced by the 
loosening of the teeth, which are soon thrown off with portions of 



CYNANCHE TONSILLARIS. ]g 5 

the alveolar process. The fluid discharged appears to have a corro- 
sive quality, for the angles of the mouth and the lower lip sometimes 
become new centres of mortification. We have known both sides 
of the face attacked in the same individual; and there are cases on 
record, iti which all the soft parts of the face, as well as the upper 
maxillary bones, the palatal, the nasal, and even the ethmoid, were 
involved in the destruction."* 

The preceding description of the disease by Dr. Symonds, as ob- 
served by him in Great Britain, corresponds entirely with the appear- 
ances noticed In this country, and especially in this city, by my 
friend Dr. B. W. Coates, who had charge of 170 cases within three 
months in the children's asylum. 

Besides those internal remedies which suggest themselves for the 
correction of the stomach and bowels, (and calomel was of the 
number,) Dr. Coates found the following local application to be far 
more ellicacious than any other. Sulphate of copper Jij, powdered 
cinchona sss, and water siv. — To be applied twice a day to the full 
extent of the ulcerations and excoriations. The cinchona is not 
absolutely necessary, but serves to retain the sulphate longer in con- 
tact with the edges of the gums. Simple ulcerations and small gan- 
grenes, adds Dr. Coates, as well as troublesome excoriation, when 
not in the last stage, yielded promptly to this remedy; the good effect 
being generally visible from the first application. 

" The separation of a portion of the periosteum from the fang, 
within the socket, which was universally found whenever the tooth 
was loose, among two or three hundred specimens, proved the exist- 
ence of the disease in a deep, narrow crevice, into which it was 
impossible, by any contrivance, to insinuate the lotion. This cavity 
was laid open by extracting the tooth ; and when the remedy was 
applied, the sanatory effect was surprisingly prompt. The universal 
rule was to extract all teeth the moment they were discovered to be 
in the slightest degree loose, and the blue wash above described 
became the standing remedy. ,, t In addition, however, the following 
prescription derived from the late Dr. Parrish, will be found ex- 
Iremi ial: Sulph. of zinc 3j., water gij. Dissolve, and then 

add of pure honey and tincture of myrrh, each ,=iij. — To be applied 
tne as the preceding lotion. 
tic potash and nitrate of silver appear to possess very little 
control over this disease, and the same remark is applicable to the 
mineral acids.] 



01 N .Weill-: TONSILLARIS.} 

Tasai are two varieties of inflammation of the tonsils: the acute 
and chronic. In the acute, the swallowing is difficnlt and painful; 

• T licine, vol. .'{ ] 

■ i ii Am. -ri' :m Med. and Surgical Joaroal, vol.2.] 

:llli>.] 



196 CYNANCHE TONSILLARIS. 

the voice is altered, and in very severe cases the respiration is im- 
peded ; the pain, generally speaking, is severe. On looking into the 
throat, the tonsils, uvula, and even part of the palate, are seen much 
swollen, and very vascular, and sometimes the throat is swollen 
externally. Loss of appetite, thirst, headache, and general fever, for 
the most part, accompany this disease ; occasionally these symptoms 
run high, and there is delirium. In some cases, only one tonsil is 
inflamed ; in others, the uvula only; sometimes white specks are seen 
upon the inflamed parts, surrounded by a viscid exudation, which 
present the appearance of ulcerations. The white specks alluded to, 
are sometimes produced by exudations of lymph; at'-others, by seba- 
ceous matter projecting from the follicles. This form of sore throat 
bears a considerable resemblance to the cutaneous affection termed 
acne. Occasionally, however, actual ulcerations are observed in the 
throat.* 

Cynanche tonsillaris terminates in resolution ; sometimes in sup- 
puration, ulceration, and sloughing. When matter forms, the pa- 
tient's sufferings are generally increased, the dyspnoea is considerable, 
and he is said, in common language, to have a "quinsy." 

The most frequent cause of this complaint is supposed to be cold, 
produced by sudden vicissitudes of weather; but I imagine there is 
a combination of causes in the production of inflammation of the 
throat, and that the principal are a disordered state of the stomach 
and bowels, and the formation of sebaceous matter in the follicles. 
Many individuals are known to me, who never have a sore throat, 
unless the stomach and bowels have been for some time out of order; 
as well as others, who for a series of years, have escaped an attack, 
by regulating themselves properly in this respect. 

Treatment. — This complaint is sometimes very little under the 
power of the usual remedies, unless it be attacked at the very begin- 
ning; and it is in such cases only, or to check the inflammation from 
running into extensive ulceration or sloughing, that venesection is 
admissible. Leeches may be applied externally, under similar restric- 
tions. It has been recommended, that they should be applied in- 
ternally to the part immediately affected ; in which last case, each 
leech is introduced by means of a tube, with a thread through the 
tail; but when it is thought necessary to draw blood from the part 
affected, it is much more easily and speedily done by scarifications, 
producing less pain to the patient. Blisters are very frequently 
useful. Females have a great objection both to leeches and blisters; 
but particularly to the former, from the marks they produce. Laxa- 
tive medicines are highly necessary, and must be frequently repeated. 
Emetics are much extolled. The best gargle, if it be necessary to 
wash the throat, is a little warm water, or acidulated infusion of 
roses. Inhaling the vapour of hot water is productive of great 
benefit, whether suppuration is to take place or not. When matter 
forms, dyspnoea frequently becomes a marked symptom; therefore, 
the sooner it is discharged the better for the patient; and it is by no 
means a painful operation, the relief being often instantaneous. 

* It has often been in my power to prove, that the sebaceous matter is one cause 
of a "bad breath." 



[INFLAMMATION OF THE UVULA.] 197 

Several fatal cases have come to my knowledge, in which it is strongly 
suspected that the immediate cause of death has been inflammation 
extending into the larynx and bronchial tubes. 

Chronic cynanche tonsillaris may either be the consequence of 
acute inflammation terminating in the chronic state, or may take 
place as the effect of sub-acute inflammatory action ; the uvula is 
found enlarged and hard, as are the tonsils. If the case be recent, 
stimulating applications are found useful, and a succession of blis- 
ters to the throat. If these means do not succeed, and the enlarge- 
ment is permaa^pt, particularly if the voice be affected, the patient 
becomes an d|Pct of surgical treatment, and the parts have been 
excised. 

Sometimes extensive and troublesome ulcerations are produced as 
the effects of chronic, as well as of acute inflammation in the throat; 
and in treating these, it is necessary, in the first place, to attend to the 
general health, by regulating the state of the stomach and bowels, 
and also the diet, which ought to consist of mild and digestible sub- 
stances. Leeches and blisters are often serviceable; but the most 
efficacious application is a solution of the nitrate of silver in dis- 
tilled water, in the proportion of four, six, and even ten grains to 
the ounce. The ulcerated surface is to be carefully washed, before 
the solution is applied. This operation, however insignificant it 
may appear, must be done with prober care, as bad consequences 
have been known to follow. There is a preparation in my museum, 
in which the epiglottis is completely destroyed by common caustic, 
rudely used, which was the cause of death. 



[INFLAMMATION OF THE UVULA.] 

[This affection often occurs independently of any considerable in- 
flammation of the surrounding parts, and trivial as it may appear at 
first thought, is often the occasion of great distress and some danger. 
The uvula not only swells and elongates by the inflammatory pro- 
cess, but becomes rapidly ocdematous, extending like a chord for an 
inch or an inch and a half into the fauces. The usual stimulating 
and astringent gargles will mostly reduce it to the natural size. Lu- 
nar caustic and alum, applied by means of a brush, are also very ser- 
viceable. But if the elongation continues, the uvula should be re- 
moved by seizing it with a forceps and excising it with a pail of long 
Sdssora I have known protracted coughs to originate with this con- 
dition of the uvula, and to disappear with its extirpation.] 



17' 



198 INFLAMMATION AND ULCERATION OF THE OESOPHAGUS. 



PHARYNGITIS OR INFLAMMATION OF THE THROAT. 

In this affection, the tonsils and uvula are not invariably inflamed, 
but upon looking, the parts being exposed to a bright light, we can 
often see the throat and pharynx very vascular, and loaded with 
viscid lymph, which the patient is constantly making efforts to dis- 
lodge by hawking and spitting. 

The pain on swallowing is fully greater than in tj^last described 
affection; I have seen patients suffering severely, Wie apparently 
in great danger. When it is recent and severe, the lancet must be 
used, followed or not by the application of leeches and blisters, ac- 
cording to circumstances. The inhalation of the vapour of hot water 
affords remarkable mitigation of the symptoms; and in slight cases, 
nothing further is required but to keep the bowels open, and allowing 
moderate nourishment. 

[Chronic pharyngitis, accompanied by extensive ulceration, has 
become very common in the United States. The ulcers are most 
frequent on" that part of the mucous membrane which covers the 
spine : they also form about the base of the tonsils, and less frequently 
on the anterior surface of the soft palate. They put on every ap- 
pearance from mere denudatfbn of the membrane, to ragged, dark, 
and livid ulcers. I have sometimes seen the whole pharynx involved 
in the disease, presenting a raw, unequal surface throughout. Oc- 
casionally it yields to the mere use of astringent gargles, especially 
the diluted creosote solution, or a strong infusion of white-oak 
bark. But in other instances they resist every form of treatment ex- 
cept that by lunar caustic, which is best applied in solution by means 
of a camel's-hair brush. This operation, to be successful, must, in 
most cases, be several, and, perhaps, many times repeated, not omit- 
ting, however, the assiduous use of gargles. 

When the ulcers have fairly skinned over, they are liable to re- 
appear on taking cold ; so that the disease becomes tenacious and 
excitable in some persons, harrassing them at intervals for years, 
occasioning much local distress, and even altering the voice.] 



INFLAMMATION AND ULCERATION OF THE 
OESOPHAGUS. 

Of all the structures in the human body, the oesophagus is, perhaps, 
the least liable to disease. In general it is difficult to detect inflam- 
mation of the oesophagus till ulceration and constriction take place. 
I have seen one case only of universal inflammation of this tube not 
caused by poison, in which the lining membrane was in a sloughing 
state. There is a preparation in my museum that displays similar 
appearances ; in this instance, however, there were no symptoms in- 
dicative of disease in the tube. In the former case which I attended, 



CHRONIC AFFECTIONS OF THE CESOPHAGUS. 199 

there were pain and difficulty in swallowing. Both patients were 
also affected with phthisis. Inflammation may be partial, affecting 
only a part of the calibre of the cesophagus ; and, if ulceration fol- 
low, there will be no contraction, but the patient will feel slight pain 
and a momentary stoppage when the bolus of food arrives at the 
spot. If the whole calibre of the oesophagus be involved in the in- 
flammation, the pain will be more considerable, not so much from 
constriction as from the effort to vomit, which is produced by irritation. 
If it terminate in ulceration, occupying the whole tube, constriction 
will. take plac^with increased difficulty in swallowing. Patients 
have been knojn to be three and four days, and even a week with- 
out food. 

Treatment. — Attention to the bowels, topical bleeding, and ex- 
tensive contra-irritation, are the best means that can be employed. 
Nourishing injections, thrown into the rectum, are to be assiduously 
administered when the patient is unable to swallow a sufficient 
quantity of food. It is the practice in such cases, to introduce instru- 
ments to dilate the cesophagus, but I have seen it very injurious in 
several instances, when the operation was performed during the 
inflammatory stage. Affecting the system with mercury has been 
highly extolled, but perhaps without sufficient consideration. If the 
constriction be permanent, after the inflammation and irritation are 
subdued, a surgeon may be called to make cautious trials with a 
bougie ; perhaps a common oesophagus tube will be found the best 
instrument for this purpose. 



CHRONIC AFFECTIONS OF THE CESOPHAGUS. 

■.times the gullet is diminished in diameter by fleshy excre- 
: tumours, or occasionally scirrhous contractions are observed; 
and mora rarely, ossification. Some individuals have survived con- 
tractions <>i the oesophagus for a great many years, being obliged to 
tod introduced into the stomach through a tube. Chronic 
i are frequently fonnd to have made consi- 
derable progress before their existence is even suspected. 

The smoke of tobacco and stramonium, the abuse of mercury, and 
drinking fluids either excessively hot or cold, have been assigned by 
orriters as the general causes, but, perhaps, too hastily. 

Of all the remedies which have been recommended to us in such 
cases, the bougie is undoubtedly the best ; and if at any time there 
should be much pain, leeching, contra-irritation, and narcotics, are to 
be had recourse- to. 

Many othei circumstances produce difficulty in swallowing, as for 
instance, want of the uvula, tumour in the pharynx, ulcerations in 
the larynx, or upon the epiglottis. The first two belong more to the 
surgical department than the medical, and therefore cannot be treated 
of in tins work ; the last two shall be noticed among the diseases of 
the respiratory organs. 



200 [DIPTHERITIS.] 



[DIPTHERITIS.] 

[The preceding varieties of inflammation (to which the more re- 
cent nosology has applied the generic name of Angina,) are liable in 
all climates to an attendant or sequela, called by M. Brettonneau 
diptheritis, and by other writers angina membranacea. This con- 
sists in an exudation or rather secretion of a lymph-like matter, which 
appears in whitish spots on the inflamed fauces, fi ||t separate, and 
few in number, and apparently connected with the f^cles ; but they 
sooner or later coalesce, and sometimes cover the entire mucous 
membrane behind the velum palati. Although its colour is generally 
white, it is not unfrequently grayish, and reddened by effused blood ; 
but in other instances it assumes a dark, ashy hue. All these symp- 
toms may accompany those of ordinary inflammation of the parts ; 
but in other cases the exudation is preceded by very little pain or 
uneasiness, while the membrane forms rapidly, and all the symptoms 
present a typhoid character. To this variety of disease the name 
angina maligna has been given. If it is not checked in its progress, 
it becomes gangrenous, as manifested by the false membrane becom- 
ing of a livid colour, and eventually black: the pain ceases; degluti- 
tion, from having been almost impracticable, is performed with ease ; 
and the cadaverous breath, which often exists almost from the first, 
becomes yet more fetid. 

This disease in its milder forms, is familiar to practitioners in the 
United States ; but in Europe it is occasionally epidemic, even in 
its malignant variety. The simple diptheritis is readily managed by 
astringent gargles, or those composed of cayenne pepper, portwine, 
brandy and salt, or salt and vinegar: so also with alum and chloride 
of lime. M. Brettonneau recommends undiluted muriatic acid; but 
the most effectual application is the strong solution of nitrate of sil- 
ver, as already directed in other forms of angina. It is a remark- 
able fact that genuine diptheritis will seldom bear general depletion, 
which increases the debility without arresting the disease ; and when 
there is the least indication of the typhoid state, a cordial treatment, 
with stimulating ingesta, becomes necessary. Counter-irritants, as 
blisters to the back of the neck, or behind the ears, and irritating lo- 
tions over the throat, are also, in most cases, indispensable. The only 
internal remedies much to be relied on, are calomel, opium and ipe- 
cacuanha, variously combined according to circumstances. When 
the disease has invaded the larynx, even independently of the ty- 
phoid condition, there is very little chance of recovery.] 



CHAPTER III. 

INDIGESTION. 

Under thisAead I shall treat of the affection which is commonly 
called dyspepsia, with its usual attendants, flatulency, tympanitis, 
pyrosis, and heartburn ; and also of the painful affection termed gas- 
trodynia. 

Dyspepsia is a most troublesome disease to treat; and I believe 
the physician, to be able to do so effectually, should have suffered 
from it himself; as one who has had the good fortune never to feel 
as if he had a stomach, can scarcely believe, or almost listen to the 
complaints of those who have experienced that sensation. One 
symptom is more prominent and urgent in one case than another; 
a little flatus in the stomach occasionally produces violent nervous 
symptoms, sometimes as if the brain were seriously affected ; and 
the whole will vanish after one or two sour eructations. Some 
patients appear as if they could not survive the difficulty of breath- 
ing under which they labour; and it will be found to depend, per- 
haps, on flatus rising in the oesophagus, producing the affection called 
globus hystericus. Remedies have not the same effect in any two 
cases; and all plans of treatment will most generally fail, unless the 
patient himself can discover what articles of food agree with him 
better than others, and has resolution enough to adhere to a proper 
regimen. 

Dyspepsia may arise from various causes. Perhaps the following 
arc the principal causes: — First, From simple functional derange- 
ment "i' ih.; stomach, duodenum, liver, spleen, or pancreas; second, 
Prom indigestible and acrid substances taken into the stomach; thin/, 
Prom structural derangements in the digestive apparatus ; fourth, 
i long-continued constipation; fifth, From derangements in 
other important organs. 

Dr. Wilson Philip, who has written on this subject, has divided 

tic disease into three stages. This plan would do admirably well, 

if dyspepsia were as regular in its march as intermittent fever; but 

in practice, such an arrangement will be found to be too arbitrary to 

• fill. 

First stater of indigestion. — The first symptoms of indigestion are 
e of fulness and uneasiness iii the region of the stomach, arising 
cither from i"<p great a load of food, from some indigestible arti 
or from flatulent distension of the Btomach ; frequent acid eructations, 
constipation, loaded tongue, and some thirst, follow. Sometimes 
throat is complained or, and a feeling in the eyes, as if sand 
were lodged between the eyelids and ball ; it is difficult to keep the 
bauds and feet sufficiently warm; and occasionally there is severe 
headache, accompanied by nausea, or violent vomiting. 



202 INDIGESTION. 

These symptoms may steal on slowly, and, from being" felt only 
occasionally, are neglected ; or they may be produced suddenly, by 
indulgence in improper food, a copious draught of very cold water, 
or from anxiety, grief, fright, or other severe mental affections, or by 
too violent exercise after a full meal. 

Physicians are rarely consulted in the first stage of the complaint; 
for the patient either drives on through it, or relieves himself by a 
day or two's abstinence, and by taking a laxative. If a person, 
however, take little heed of himsejf, he is soon heard to complain of 
restless nights, oppression at the prascordia, and beccjmes sensible of 
diminution of strength and heat of skin ; his appetite becomes fas- 
tidious; he is either very costive, or is affected with diarrhoea. The 
alvine discharge is sometimes very bilious ; at others white, showing 
a want of bile; it is adhesive, drops with difficulty from the body, 
and is very fetid. After the patient obtains passage from the bowels, 
he still feels much loaded, and very often considerable quantities of 
half-digested food will be observed in the stools. 

Persons labouring under such symptoms will very generally be 
heard to attribute their complaints to a "fit of the bile;" and many 
medical men, I fear, confound stomach disorders with those of the 
liver, and too frequently exhibit powerful mercurial preparations, 
to the great injury of the patient. 

Treatment of the first stage. — The cure of this form of the com- 
plaint is not difficult. The patient is to be directed to abstain from 
the use of soups, and whatever else distends the stomach ; to eat and 
drink little, and to leave off while he has still an appetite ; to keep 
his bowels open with a little rhubarb, Henry's calcined magnesia, or 
a compound colocynth pill ; and to take regular exercise. He should, 
as much as possible, avoid any cause which has a tendency to pro- 
duce either mental excitement or depression. 

The second stage of indigestion is marked, according to Dr. 
Wilson Philip, by the supervention of tenderness in the epigastric 
region, and a hard pulse ; and he very justly considers these two 
symptoms of much practical importance. The patient now feels 
very sensible to the impression of cold ; he is often chilly, and after- 
wards complains of flushes of heat; his hands and feet have some- 
times a dry, burning sensation, particularly during the first part of 
the night, extremely cold at other periods, painfully so when he 
first goes to bed; his skin becomes hot in bad cases, but towards 
morning a perspiration breaks out, and the patient enjoys some quiet 
sleep. When he awakes, although he may complain of not feeling 
refreshed, yet the symptoms are greatly relieved. His debility is 
now greater, with some emaciation ; he complains of languor, and 
always desponds. There are considerable uneasiness and fulness in 
the epigastric region, and an occasional darting pain towards the 
spine, together with a burning sensation in the stomach. Palpita- 
tions are now, perhaps, very troublesome ; they are not constant, 
but become worse after dinner ; the least thing agitates the mind, 
and produces them. The patient sometimes coughs and expectorates 
in the morning, and supposes he is consumptive ; or there are vertigo, 
and sometimes violent headache, with imperfect vision, as, for in- 



INDIGESTION. £03 

stance, seeing two objects instead of one, or only half an object; and 
it is impossible to persuade him that he is not threatened with 
apoplexy. 

In cases of dyspepsia, some individuals, particularly those with 
light hair, are very liable to inflammation of the tarsi, with purulent 
exudation ; and sometimes little abscesses form, which are called, in 
common language, « styes." The kidneys frequently suffer, the flow 
of uriue being either too sparing or too copious, attended with com- 
plaints which are called " gravelish." It is my belief that dyspeptics 
are more liable than others to inveterate skin diseases, and to stone 
in the bladder. It will be found also that most of the individuals 
who labour under hemorrhoidal affections are dyspeptics; and it 
may be mentioned, that I have rarely seen a person afflicted with 
fistula in ano, excepting when it proceeded from external injury, 
who has not been a martyr for a long period to this class of com- 
plaints. Pure surgeons should make themselves acquainted with 
these facts and a great many other points of medical pathology. 

It is rare to observe all these complications, but they are occasion- 
ally met with in the same patient. I have seen many persons con- 
sider their lives as burthens to themselves, and there is often a strong 
tendency to commit suicide. 

Should the symptoms continue severe for a considerable time, some 
serious organic lesion may be dreaded; but the lungs, liver, kidneys, 
and brain, are the organs that most frequently suffer, and form what 
may be termed the third stage of dyspepsia. 

Treatment of the second stage. — Whenever the patient complains 
of tenderness in the epigastric region, with a hard pulse and bad 
nights, local bleeding by cupping or leeching frequently produces the 
best effects. My own plan, in severe cases, is to apply leeches, to 
the number of twelve or eighteen, two or three times if necessary, 
before coutra-irritation is had recourse to ; and the best method of 
producing irritation, is by frictions with the tartrate of antimony 
ointment, which must be persevered in, first on one part then on 
(mother, BO as to produce a succession of pustules. I have been led 
to place much dependence 00 this practice, by observing that dyspep- 
tics have sometimes been relieved, at others cured, upon the ap- 
pearance of a spontaneous eruption. In severe cases, the diet should 
-i of gruel, arrow-root, milk, calf-foot jelly, light podding, and 
good bread; and these should be allowed in limited quantity; more 
than a breakfast teacupful at a time will overload the stomach. 
Soupfl and vegetables should be avoided; at least for some time. 
Gentle laxatives, so as to open the bowels twice a-day, are to be 
mtd. Tin: tepid bath will be found very useful; but perspiration 
must not be encouraged after coming out of the bath. The patient 

should be clad according to the season of the year ; and it is of great 

equence to keep the feel comfortably warm and dry; in order 
to ensure tins, worsted stockings are too frequently directed to be 

worn, which, m many individuals, will produce the very circumstance 
it is Wished to avoid. It was a long time before 1 could discover 
the cause of this; and I believe I may now state confidently, that 
worsted stockings, worn by people whose feet perspire, will tend to 



204 INDIGESTION. 

produce coldness of the extremities. In such circumstances, I find 
the object is attained, if the patient wear an under stocking either of 
silk or thin cotton. Exercise in the open air is highly necessary as 
soon as the patient's strength will permit; if he ride on horsehaclc, 
the feet should be additionally protected in cold weather by cloth 
boots, and he should never make use of horse exercise for two or 
three hours after a meal. By degrees, he may be allowed a small 
teacupful of chicken or beef tea; subsequently, he may eat part of 
the breast of a chicken or game to dinner, till he is able to return to 
ordinary fare. The physician, in severe cases, ought to insist on his 
patient keeping notes of his diet, particularly during his recovery, 
which will enable him to compare his present state of health with 
the articles he had eaten the day before. The best diluents he can 
use are, an infusion of chamomile flowers and lemon-peel, and wine 
and water in small quantity. Stimulants are to be commenced with 
great caution, and not until the pain in the epigastric region and heat 
of skin are subdued; perhaps the best stimulant is cayenne pepper 
with food, which affects the whole bowels as well as the stomach, 
and tends to obviate constipation. Ginger tea will be found service- 
able, together with a glass or two of good sound wine once or twice 
a-day. Wine, sometimes, however, produces acidity, in which case 
a small quantity of brandy in water is found an agreeable substitute. 

Dyspepsia is one of those diseases too generally treated by the 
routine practitioner, from its name, without reference to the patho- 
logical condition of the body on which the numerous symptoms de- 
pend. If such a practitioner were asked what he would prescribe 
for a person who had dyspepsia, he would quickly reply, tonics ! 
I have no objections to the medicines which are usually administered 
under the denomination of tonics, provided they are not given for 
the purpose of running up a bill, or prescribed at times when some- 
thing better might be done for the patient. But I have some doubts 
respecting the truth of the received notion of their action ; I do not 
think it is by giving tone to the stomach. These remedies are gene- 
rally bitter, and, I imagine, produce increased secretion of the fluids 
connected with the digestive process. On putting a little quassia or 
gentian into the mouth, immediately a flow of saliva takes place, 
which continues as long as the taste is perceptible, and even after- 
wards, when the person thinks of the bitter taste. May not a simi- 
lar action, in other organs, follow the application of the same sub- 
stance ? 

If the liver be not doing its duty properly, calomel, hydrargyria 
cum creta,or the blue pill, may be occasionally exhibited at bed-time, 
followed by a very small dose of salts in the morning; but it is a 
despicable practice to give blue pill in every disease connected with 
the digestive function. And it is much to be regretted, that the great 
name of Abernethy should ever have been associated with such in- 
sufferable quackery. 

The above treatment is to be persevered in for a long time, chang- 
ing the diet and the laxatives now and then, but continuing the con- 
tra-irritation and application of leeches alternately. After a time, 
cold bathing in the open sea may be cautiously tried; the shower 



INDIGESTION. 205 

bath, or sponging the body with vinegar and water, often produces 
the best effects. 

Third stage of indigestion.. — It is not necessary to give a de- 
scription in this place of the symptoms in the third stage of indiges- 
tion, and the proper mode of treatment, because these must vary 
according to the organ diseased, as well as the nature and extent of 
the affection. 

The disease termed dyspeptic phthisis, by Dr. Wilson Philip, is 
only met with, generally speaking, in cases of long standing. My 
experience, however, leads me to state that bronchitis is the primary 
affection in such cases; the tubercles form subsequently, and only in 
subjects highly predisposed. 

Flatulency and Tympanitis. — These are symptoms of dyspepsia, 
but require a few separate remarks, along with water-brash and 
heart-burn. 

Some people suffer extremely from flatulency and acrid eructa- 
tions. Five or six instances have fallen within my observation, of 
individuals who frequently passed enormous quantities of flatus up- 
wards ; and it is presumed these are cases to which Dr. Mason Good 
would apply the term cholera Jlutulenta. In all such instances, the 
patients had previously eaten some crude vegetable substance: gene- 
rally, the ordinary salad mixture, or radishes. The remedies which 
seemed to afford the greatest relief were aether, aromatic spirit of 
hartshorn, warm brandy and water, or brandy by itself, and essence 
of peppermint. 

Tympanitis may be detected by percussing the abdomen; it is 
often a troublesome symptom, not only in this affection, but in fever; 
and the best remedy which can be used is turpentine. It is better to 
try it, in the first place, by injection, in the proportion of a table- 
spoonful to eight or ten ounces of thin gruel, which the patient is to 
retain as long as possible. If this plan does not succeed, half an ounce 
is to he given by tin- mouth with the same quantity of castor oil. 

Infants, during the first months, frequently suffer very much from 
flatus in the stomach and bowels, wlneli will in general he found to 

depend "ii ihe pernicious ami unnecessary custom of giving them 
ii nil and other medicines to open their bowels, and food they are 
unable to digest. Iii truili, the moment an infant is born, and often 
before it is dressed, castor oil is exhibited, which frequently produces 
griping; this is attributed to wind, and want of something to eat, 
therefore a quantity of gruel is then given, which often increases the 
child's sufferings; Dal by 's carminative is at last exhibited, which 
affords temporary relief. Few infanta can be expected to thrive well 
under Buch bad management. The usual remedies for Satulence in 
infancy an 1 , <hii water and oil of aniseed. 

Pyrosis, or Water-brash. — In some long standing cases of indi- 

'ii. particularly in old people, in women more than men. and 

those who live principally upon farinaceoua food, a considerable 
quantity of limpid Quid is discharged from the Btomach by eructa- 
tion. This is the affection which is called water-brash. It is a Symp- 
lon of scirrhua of the stomach also. 
It attacks the patient generally in the morning and forenoon-, at 

18 



206 GASTKODYNIA. 

first considerable complaint is made of pain in the pit of the stomach, 
faintness, a sense of tightness, as if the stomach were closely drawn 
up to the back bone, and the uneasiness is increased upon moving 
into the erect posture ; at last the limpid fluid is discharged in con- 
siderable quantity at different times, when the pain subsides ; some- 
times the fluid has an acid taste, but in general it is stated to be in- 
sipid. Occasionally the discharge takes place without being preceded 
by any severe symptom. Laxatives and the oxide of bismuth, to- 
gether with change of diet, are the best remedial agents in this com- 
plaint: 

Heartburn is, next to flatulency, one of the most frequent symp- 
toms in indigestion, and it is also one of the common attendants on 
pregnancy. When heartburn exists, the patient complains of a 
burning pain in the pit of the stomach ; every kind of food creates 
acidity; and hot, acrid eructations take place, which seem to irritate 
the oesophagus. Some women suffer very much from this symptom 
during the whole course of pregnancy, but the moment delivery takes 
place, it generally vanishes like magic. 

Henry's calcined magnesia, and careful attention to the diet, often 
mitigate this symptom. The carbonate of soda and potass are fre- 
quently used, and sometimes with benefit; as also, charcoal and 
chalk mixture. The remedy which will be. found most successful in 
producing temporary relief, is the common extract of liquorice. Cases 
are now and then met with which resist all these remedies, together 
with leeches and opiates. The oxide of bismuth, in doses of 15 or 20 
grains, is often serviceable. Sulphate of iron, and sulphate of zinc, 
have been highly extolled. I have exhibited them often in such in- 
stances, but without benefit. The points to be chiefly attended to, 
are the regimen and laxatives. 



GASTRODYNIA, OR GASTRALGIA. 

The stomach is liable to a neuralgic affection, which is known by 
this name, as well as by the term Cardialgia. Gastrodynia is closely 
connected with dyspepsia, often occurring as a symptom ; but it may 
exist as the primary disease ; sooner or later, however, the digestive 
powers suffer. 

Symptoms. — Sometimes the appetite remains good, but in general 
it is impaired. There is gnawing pain in the stomach, extending 
very deep to the back, accompanied by anxiety, sense of constriction, 
tendency to eructate or to vomit, with occasional faintness, some- 
times headache and constipation, and the patient is occasionally 
relieved by eructation ; a considerable quantity of limpid fluid is 
sometimes discharged ; in fact, this affection is often complicated 
with pyrosis. After a severe attack, a patient sometimes escapes 
without another, for a week, a month, or even a longer period. 

All the symptoms enumerated do not take place in every case ; 
sometimes there being only pain and anxiety, with some nausea, 



GASTRODYNIA. 207 

which are increased after taking food. This affection is almost un- 
known before the age of puberty. Besides, depending on a diseased 
condition of the nerves of the stomach, it is probably occasioned by 
a diseased state of the pancreas, spleen and liver. Sometimes it is 
produced by scirrhosities of the stomach and duodenum, and it is also 
a very troublesome attendant on gout. This disease has, of late years, 
excited a great deal of interest in France, as well as in this country; 
and although no additional light has been thrown upon the nature 
and seat of the disease, still very considerable practical advantages 
cannot fail to be derived from perusing the writings of M. Earras, 
and Dr. James Johnson. 

The chief causes of gastrodynia, generally speaking, are supposed 
to be long-continued use of indigestible food, very hot or very cold 
drinks, dram-drinking, long fasting, worms. The chief articles which 
produce a paroxysm in an individual liable to the affection, are salads, 
and other crude, uncooked vegetable substances; cheese, sweetmeats, 
new bread, cherries, nuts, olives, and above all, perhaps, roasted 
chestnuts. The cure depends, therefore, upon avoiding such articles 
in future, together with fat, oils, and butter. 

During an attack, a vomit will often suddenly check it, if exhibited. 
within two or three hours after the offending matter has been eaten; 
hot flannels are to be applied to the epigastric region; gentle laxa- 
tives, and the warm bath, are to be employed, together with bitters, 
alkalies, magnesia ; and, in bad cases, contra-irritation is to be per- 
severed in for a considerable time. I have known one or two pa- 
tients, who, for many months at a time, could not put any kind of 
food into the stomach, without previously taking a small dose of the 
sedative solution of opium ; and we are told by Roche and Sanson, 
that, in the worst form of this disease, which had resisted bleeding, 
bitters, and antispasmodics, Dr. Francois found lactucarium suc- 
cessful. It is a curious fact, that, although sweet things generally 
ivate the complaint, the extract of liquorice frequently alleviates 
pain considerably. M. Barraa insists much upon the necessity 
of making the patient take animal food, although it may, for the 
lime, iucrease his sufferings ; but to this treatment I cannot subscribe 
my assent — that kind of food is best for the patient which occasions 
the least distress after it is taken into the stomach. 

[Much use has recently been made of the sulphate of morphia, in 
• I one-eighth or one-sixteenth of a grain, given three or lour 

limes a day, ami persisted in. l)v. .lanes Johnson has strongly re- 

commeuded tie; nitrate of silver, viz. j iu pills containing the eighth 
pan of a grain, or even the half of thai quantity, repeated twice or 

thrice a day. This should he accompanied hy a hot saline foot-hath, 

daring the paroxysm of pain. The preparation known as Warner's 

cordial, with the morphia added, should he taken in a draught of 
Water as hot as the month will hear it. Mustard plasters to the sto- 
mach will also he a gn at relief during the emergency.] 



CHAPTER IV. 

DISCHARGES OF BLOOD FROM THE STOMACH AND 
BOWELS. 

I. Hcematemesis— Haemorrhage from the stomach. — This form, 
which is termed haematemesis, is sometimes occasioned by diseases 
of the liver and spleen, and takes place also occasionally in fevers; 
but these are not under consideration at present. 

Haematemesis most frequently attacks women, particularly those 
who are unmarried, of a plethoric habit, and at times when there is 
an obstruction, or some other irregularity of the menstrual discharge, 
and who are constipated. Each attack is generally preceded by a 
rigor. Pure blood is seldom vomited, unless from external violence, 
or the erosion of the coats of a blood-vessel. This discharge rarely 
coagulates, and seems rather to be the product of passive haemorrhage, 
or exudation from the minute vessels of the mucous membrane. It 
is supposed to be a very easy matter to distinguish this affection from 
those haemorrhages which take place from the lungs. In haemate- 
mesis, it is said the discharge is preceded by a sense of weight, pain 
in the region of the stomach, and that it is unaccompanied by cough, 
&c. But these distinctions will not answer in practice, and it may 
be of great consequence to a medical man, that he should not give 
an assurance of safety, in a case which may prove fatal in a few 
minutes, as the following instances will show. A child was attended 
by Dr. Yates, when that excellent gentleman was a pupil at my dis- 
pensary. It had been for some time complaining of cough and 
anomalous symptoms, which were relieved from time to time, and 
it was able at last to go to school as usual. Still it occasionally 
discharged a little blood, and died suddenly after vomiting a con- 
siderable quantity. On dissection, the stomach was found filled with 
a coagulum, and there was also a considerable portion in the small 
intestines in a fluid state. It was evident that there had been active 
haemorrhage, but after the most minute investigation, no blood-vessel 
could be found from which it had issued. The relations began to 
complain of the time we had been over the body, and at length 
became very impatient, so much so, that we were obliged to give up 
further examination; but the whole of the contents of the thorax, 
including the oesophagus and great vessels, having been carefully 
dissected out, were surreptitiously conveyed to my museum for mi- 
nute inspection; and it was discovered that the blood found in the 
stomach and bowels, had proceeded from a ruptured artery in a 
cavern in the superior lobe of the left lung. A fistulous opening was 
found running upwards from this cavern, and communicated high up 
with the oesophagus; so that when ulceration produced a rupture of 



[DISCHARGES OF BLOOD.] 209 

the vessel, the blood passed in this direction, and found its way into 
the stomach. The preparation is in my museum, together with an 
accurate and beautiful drawing by my friend Dr. Alexander Thom- 
son, an enthusiastic pathologist. 

Another remarkable case occurred in the dispensary practice, in an 
old man. He had enjoyed remarkably good health until lately, when 
his appetite became impaired, and he complained of dyspeptic symp- 
toms, which gradually increased in severity, and he was at last 
reluctantly obliged to seek for medical advice, at the age of seventy- 
two, for the first time I believe, in his life. He complained of so 
much uneasiness in the region of the stomach, that he was cupped 
several times, and contra-irritation was produced over the part af- 
fected, with considerable relief. One morning he discharged a little 
blood, between the act of coughing and vomiting, and he soon died 
after passing a considerable quantity. Upon dissection, it was a 
subject of general remark, that the external appearance of his body, 
as to shape and plumpness, was more like that of a man half his age. 
Every internal organ appeared sound ; but on cutting through the 
stomach into the duodenum, the pylorus was found thickened and 
indurated, and an ulcer about the size of a horse-bean was discovered 
in the duodenum, on the surface of which, the gaping mouth of a 
large artery was discovered, from which the haemorrhage had taken 
place. 

[The diagnosis is certainly difficult in some instances, especially 
when there is reason to believe that the patient may have swallowed 
blood which has oozed from the nose, mouth or pharynx. I once 
ted at the examination of the body of a child that had died 
from haemorrhage from the gums which had been lanced by the at- 
tending physician. The bowels were absolutely distended with blood, 
and a portion of it yet remained in the stomach. But for a know- 
ledge of the cause, how complete would have been the deception ill 
this instaucr? The safest diagnosis will be derived in a great mea- 
sure from the pre-existing Bymptoms, which are not confined to "a 
i hi pain in the region of the Btomach," but also embrace a 
_■ languor, nausea, weigh) and preternatural heat, extending 
through the right hypochondriac region. The vomiting Is Bomelimes 
delayed for many hours, and even for several days, and is usually 
followed by syncope, with its usual attendants: unconsciousness", a 
cold, clammy skin, temporary cessation of pulse and visible res-pi ra 
tiou, and in fact, all the appearances of death itself. 

The blood thus thrown up, unlike that from haemoptysis, is for the 
most pari dark and coagulated, ami besides being ejected by the act 
dt vomiting, is usually accompanied by, and mixed with the injesta 
of the stomach. There is, moreover, extreme tenderness of the <-pi- 
gastriura throughout the attack ; and my own experience has seldom 
exhibited haematemesia in a plethoric person. <)n the contrary, nearly 
all the instances that have come under my notice have occurred in 
attenuated constitutions, — thin, delicate, and more or less inclined to 
anemia,— with little or do antecedent febrile excitement To this 
rule, habitual drunkards form an exception. They are, perhaps, 

13» 



210 [DISCHARGES OF BLOOD] 

particularly liable to it, and the attacks are characterized by every 
grade of fever. 

Heematemesis is very rare in childhood, and unfrequent in the de- 
cline of life; and it is more common in women than in men, being 
often in the former a vicarious haemorrhage. 

The quantity of blood lost is sometimes truly frightful; yet 1 am 
satisfied that in most of the cases I have met with, the haemorrhage 
was of the passive kind, never owing to the rupture of blood-vessels, 
but in every instance a simple exudation from the mucous membrane. 
I have seen three deaths during the haemorrhage itself; and in the 
worst of these, a most careful inspection of the alimentary canal, 
which was literally filled with blood, led to the decided conviction - 
that the disease consisted in a mere sanguineous exudation. Ero- 
sions of the stomach from cancerous and other ulcers are, neverthe- 
less, of frequent occurrence, but are attended by a train of symptoms 
which readily leads to a correct diagnosis.] 

Treatment. — As the disease generally attacks plethoric indi- 
viduals, and is seldom accompanied by debility or oppression, prac- 
titioners have no scruple in employing blood-letting during an attack, 
and it is frequently speedily successful in checking the discharge, by 
altering the determination of blood, and reducing the force of the 
circulation. Quietness, cold acid drinks, and a course of laxative 
medicines, are also essentially necessary. If the haemorrhage recur 
after bleeding, or should it take place in a constitution already de- 
bilitated, the acetate of lead, either in solution or in the form of pill, 
in doses of two or three grains, and one of opium, every second or 
third hour, will be found serviceable. [I have never seen a case 
that would bear bleeding, as may be inferred from the foregoing 
remarks. Mustard to the epigastrium and extremities, and the in- 
ternal use of the muriated tincture of iron, or spirits of turpentine, 
are all the resources which I can add to those enumerated above.] 

II. Haemorrhage from the bowels. — This was formerly known 
by the term haemorrhoidal flux, and it was believed by the ancients 
to be salutary ; but now such a discharge is always regarded with 
anxiety, as it tends to undermine the constitution, and, like other long- 
continued haemorrhages, leads to affections of the brain — a remark- 
able and fatal instance of which lately fell under my observation. 

[Every part of the mucous membrane of the alimentary canal, is, 
perhaps, equally subject to haemorrhagic exudation. Occasionally 
the inundation of blood is so great as to give rise to sanguineous 
cholera. The diagnosis is simple; for, if there be no vomiting, we 
of course refer the disease to the bowels, and especially when the 
blood is ejected unaltered. We might at first suppose the latter 
symptom to indicate piles; but I have seen red blood voided in large 
quantity at the same time that it has been thrown up from the sto- 
mach, thus removing every doubt as to the nature or origin of the 
haemorrhage. 

Intestinal haemorrhage for the part, however, assumes the form or 
character called meleena, in which the stools are of a black or very 
dark colour, and extremely offensive. Sometimes they resemble ink 



[DISCHARGES OF BLOOD.] <2H 

mixed with sand, or black paint. The first discharges are generally- 
hard or scybalous, but those which follow become looser, and are 
more apt, for obvious reasons, to be mixed with pure blood. This 
condition may exist for days without its being suspected ; and I have 
known instances in which it was only discovered by a casual notice 
of the discharges, which, from their black colour, excited appre- 
hension. 

The symptoms which mark melaena, do not materially differ from 
those of haematemesis, excepting, as already observed, the absence 
of vomiting. 

Although these haamorrhages are to be regarded for the most part 
as simple exudation resulting from a congested state of the mucous 
membrane, there can be no doubt that the liver is sometimes involved 
in the same pathological condition, and relieves itself of congestion 
by pouring its blood into the duodenum. Whether Dr. Ayre was 
right in ascribing this pathological condition to "the minute ramifi- 
cations of the portal vein in the glandular texture of the liver," we 
will not attempt to decide; but his general position appears to be 
founded in fact. 

We need hardly remark that haemorrhage from the bowels, like 
haematemesis, is often symptomatic of other diseases, as carcinoma, 
ulcers, the low forms of fevers, dysenteric affections, &c, but the 
diagnosis in these cases is seldom difficult. 

The treatment is much the same as in haematemesis, excepting 
that moderate purging with mercurial cathartics, combined with 
opium, is for the most part requisite. These should be accompanied 
by enemata of an active kind ; and after the bowels have been freely- 
evacuated, cold drinks, and especially a weak solution of elixir of 
vitriol, sweetened with sugar, or simple vinegar and water, will act 
favourably as a check to the haemorrhage. Acetate of lead and 
opium, or alum in pills, or the aqueous solution of creosote, in small 
and repeated doses, will serve the same purpose. This disease, like 
bsBBiatemesis, is most frequently observed in the atonic state, and is 
Consequently passive; bat where it is attended, as is sometimes the 
. with plethora and active fever, the general treatment must be 
mis. The topical applications should be cups or leeches over 
the epigastric or right sacro-iliac region, followed, if the case be 
urgent, by resicatoriea 

In that hemorrhage which follows or attends the low or ataxic 
fbmifl of fever, nothing acts so promptly and so beneficially as the 
spirits of turpentine, in doses of ten or fifteen drops every hour or 
two hours, m emulsion. 

I have never met with a case of idiopathic intestinal hemorrhage 
that would bear venesection; but, on the contrary, after the bowels 
ha\<- hern evacuated and clean ted, the diet should he light and nutri- 
tious, and even gently stimulating; as wine-whey, the farinaceous 
articles flavoured with brandy, weak milk punch, animal and vege- 
s jellies, Bus. The propel period for interposing stimulants, how- 
evcr, is a point that requires caution; at the same tune that a neglect 
of them may prove fatal to the patient.] 



212 DISCHARGES OF BLOOD. 

III. Piles, or haemorrhoids. — When blood is discharged by stool, 
it will sometimes be found to proceed from an injury done to the 
verge of the anus by the hard and constipated stool, from a ruptured 
blood-vessel in the bowels, or from the diseased excrescences which 
are found at the termination of the rectum, known by the name of 
haemorrhoids, vulgarly called piles. These have been divided into 
two kinds, external and internal, which last are also called blind 
piles. They may be said to be painful excrescences on the verge of 
the anus, or in the rectum, usually attended with a discharge of 
mucus or of blood. 

The profession is not agreed as to their pathology; but after a 
careful examination of the opinions which have prevailed, and of 
the diseased parts themselves, I feel disposed to believe there are 
at least four distinct kinds of haemorrhoids. 1st, They are sometimes 
nothing more than a varicose state of the haemorrhoidal veins with, 
perhaps, a slight thickening of the mucous membrane of the rectum 
itself. 2d, They are formed by an effusion of blood in the sub- 
mucous tissue, which may either be subsequently absorbed, or be- 
come organized, with a slight thickening of the membrane. 3d, 
They are mere fungosities from the surface of the mucous membrane; 
and accordingly are found to vary very much in size, shape, and 
appearance, 4th, A prolapsed state of the mucous membrane of the 
rectum, which subsequently becomes indurated, and in a manner 
strangulated, by the contraction of the sphincter. 

Symptoms. — Individuals who are thus afflicted, suffer only occa- 
sionally, and then, it is said, in common language, they have "a fit 
of the piles." A sense of heat and fulness is felt in the rectum, 
attended with an occasional stinging pain, which is sometimes very 
severe and darting, increased when at stool, during which a quantity 
of blood is discharged, and a strong desire is experienced to sit and 
strain. After this has subsided, a sense of heat is felt for a few 
minutes. But when the piles are external, they often swell enor- 
mously; are very tender, however small they may be, and sometimes 
ulcerate. In this case the discharge may be constant, taking place, 
however, in small quantity at a time ; on other occasions, there is 
copious haemorrhage, followed by temporary relief from pain. When 
the inflammation runs high, induration of greater or less extent is 
left, in consequence, most probably, of effusion of lymph into the 
cellular membrane, to which strictures of the rectum may frequently 
be traced, and the formation of small hard tumours close to the verge 
of the anus. 

Causes. — The injury done to the parts by the frequent passage of 
indurated faeces ; the use of aloetic purges; long-continued exercise 
in the erect posture; sitting on a cold or damp seat; and every cir- 
cumstance which impedes the flow of blood through the veins of the 
abdomen — are causes of this complaint. The pressure of the gravid 
uterus, therefore, is sometimes a cause, as well as tumours affecting 
different parts of the uterine system, and diseases of the liver, &c. 
But it will be almost invariably observed, that individuals, affected 



DISCHARGES OF BLOOD. 213 

with piles, have been long and seriously afflicted withgastro-intestinal 
irritation.* 

Treatment. — The bowels must be kept constantly well regulated 
by the gentlest laxatives, carefully abstaining from the use of aloes 
in any shape. A large mucilaginous injection, exhibited immediate- 
ly before going to stool, will be found highly serviceable, and the 
best way of preparing it is by making a decoction of linseed. Sul- 
phur has been erroneously supposed to be a specific. Balsam of 
copaiva was recommended by Dr. Cullen as an injection ; but in 
the ordinary cases of blind piles, gentle laxatives, occasional injec- 
tions of decoction of linseed, or of sulphate of zinc, or alum, together 
with rest in the horizontal posture, and a moderately antiphlogistic 
regimen, will suffice. When the piles are external, tender, and in- 
flamed, the application of leeches, or punctures made with a lancet, 
are often productive of great benefit, by diminishing the tension and 
pain. In severe cases, the recumbent posture is actually necessary, 
and I have seen the inflammation run so high, and attended with so 
much suffering, as to require general bleeding. Poultices and warm 
fomentations are very serviceable in alleviating the pain, and some- 
times anodyne injections must be had recourse to; considerable relief 
is obtained, if the excrescence can be pushed within the sphincter. 
An ointment, made by mixing equal parts of powder of galls and 
opium in hog's lard, and a weak solution of nitrate of silver, are fre- 
quently beneficial. [The fresh leaves of stramonium, pounded with, 
crumbs of bread to the consistence of a poultice, afford great relief.] 

If a great deal of blood be lost, whether at once or at ditferent 
periods, a careful examination should be made with the eye, as well 
as the finger, in order to ascertain the exact point from which the 
bleeding proceeds; and it is necessary sometimes to apply caustic, a 
ligature, and even the knife; but these are matters of surgery. I 
would only further beg to insist upon the necessity of attending to 
the constitution more than is generally done in these cases, and par- 
ticularly to the general condition of the mucous membranes; and 
young practitioners should bear in mind, that neglected cases of piles 
often terminate in fistula. 

• T ■ p rniciooa babil ol taking a bo ik or newspaper to read In the water-closet, 
an ancomnn i nt complaint, 



CHAPTER V. 

COMMON COLIC ; PAINTER'S COLIC ; ILEUS, INTUS-SUSCEPTION J 

INTESTINAL CONCRETIONS; PI'.OLAPSUS ANI J AND 

CONSTRICTION OF THE RECTUM. 



COMMON COLIC. 



Common colic may be produced, among other causes, by indi- 
gestible food, constipation, and a diseased condition of the biliary 
secretion. 

Symptoms. — Griping pains and flatulent distension of the bowels, 
with a sense of twisting in the region of the navel, are felt, some- 
times, with contraction of the abdominal muscles: and, occasionally, 
though rarely, with some degree of nausea and vomiting, which 
takes place more frequently, when the affection is produced by the 
biliary secretion, and in which case there is generally looseness of 
the bowels. Flatus is sometimes heard rumbling backwards and 
forwards in the bowels, which is more classically termed borboryg- 
mus. The pain comes on in paroxysms, during which the patient 
thinks he experiences relief by pressure applied to the abdomen, 
which in general distinguishes the affection from others of an inflam- 
matory nature. But it must be recollected that cases of colic, when 
neglected, often terminate in inflammation of the bowels. 

[Sometimes the disease is attended from the outset by spasmodic 
and very painful contraction of the abdominal muscles, (which gather 
into knots under the finger,) which seems to be propagated from the 
bowels themselves, giving rise to intense pain. The abdomen is 
hard and distended with wind ; the pulse is tranquil, owing to the 
absence of fever, and the countenance, during the intervals of pain, 
resumes its natural expression. The latter circumstances contrast 
with the ordinary symptoms of enteritis, with which colic may be 
confounded ; but, after colic has continued for some hours, the pulse 
often becomes irritable, the abdomen sensitive, and the symptoms 
assume an inflammatory or febrile character. The most serious 
mistake which can result from a careless examination of the patient, 
is that of overlooking a hernial protrusion, which has sometimes 
remained undetected until fatal consequences have followed.] 

Treatment. — It is a most essential point to obtain free evacua- 
tions from the bowels speedily, particularly by means of an injec- 
tion; certainly the best is composed of tobacco, in the proportion of 
half a drachm infused for ten or fifteen minutes in eight or ten ounces 
of boiling water; to be strained, and exhibited when sufficiently cool. 



[COMMON COLIC] 215 

If the attack succeed immediately after a meal, an emetic may be 
given to dislodge the offending matter. Oil of cloves should be ad- 
ministered along with castor oil, or any other purgative; or oil of 
turpentine may be used by injections. Warm fomentations to the 
abdomen, or the general warm hath, may be employed. 

Some cases of abdominal inflammation are attended by symptoms 
so slight as to resemble colic very closely ; so much so, that in many 
instances it is difficult, and in some impossible, to determine this 
point of diagnosis. 

In such circumstances, it will be well for our patients if we do not 
attempt to refine too nicely; if, in doubt whether the case be one of 
inflammation or of colic, it is our duty to give the benefit of that 
doubt by using the lancet, particularly if the bowels are obstinate. 
[If the pain be severe, bleeding had better be resorted to without 
delay, inasmuch as it not only relieves the pain sooner than any other 
remed?, but at the same time renders the bowels much more readily 
acted on by cathartics.] The advantage of opium is very doubtful 
till the bowels have been properly moved, and the evacuation ex- 
amined. [If, however, the violence of the pain demands it, it should 
be combined with free doses of calomel, viz. : five grains of the latter 
with a gram or two of opium every hour or two until relief is ob- 
tained. I have also seen sreat benefit derived from heating brandy 
and cloves together and applying the decoction, by means of flannel 
wrung out of it hot and dry, and applied frequently to the abdomen. 
A hot saline pediluvium contributes to the same end. 

In flatulent colic when the distension is great and the distress in 
great measure is owing to that cause, I have seen great relief derived 
from the insertion of a gum-elastic tube, (ihe stomach tube, for ex- 
ample) into the rectum, and by giving it additional firmness by means 
of a slender whale-bone, passing it up cautiously as high as possible. 
The- quantity of flatus which sometimes escapes in this way is truly 
remarkable, as is also the relief which follows it. 

I have- pursued the same plan in the obstinate constipation of bili- 
ous colic; and can recur with peculiar gratification to the case of a 
eman whose symptoms, after resisting every other plan of treat- 
ment for live days, and at a tune when nature was almost exhausted 
and death seemingly at hand, yielded to a strong injection of senna 
throwu high into the bowels through a Btomach-tube. In this in- 
stance I succeeded in passing the instrument through the sigmoid 
fl< cure and up the left descending colon into the arch, and along the 
latter to the right side of the abdomen; until, in the words of the 
patient, the instrument touched the Beat of Ins disease. Immense 
-tit evacuations immediately followed, the obstruction was re- 
moved, and the recovery, under a cordial treatment, was rapid and 
complete, | 

In a case of colic from vitiated bile, diluents, such as barley-water, 
are to be employed, together with a weak solution of salts, and after- 
wards opiates, [fine bowels be open, and we are perfectly satisfied 
that there is no danger ol inflammation, a stimulant, such as brandy, 
is often beneficial. 

Some women, at the menstrual periods, have griping pains in the 



216 PAINTER'S COLIC. 

bowels, more particularly in the course of the colon, accompanied by 
considerable distension of the abdomen, attended or not by consti- 
pation ; frequently the pain extends from the caput caecum to the 
arch of the colon. The best remedy, in such cases, is a turpentine 
or assafoctida injection, combined with warm fomentations, proper 
regulation of the bowels and diet, and sometimes the warm hip- 
bath. 



COLICA PICTONUM.— PAINTER'S COLIC. 

This is also known by the names, colica pictonum, Devonshire 
colic; and in the West Indies it is commonly called dry belly-ache. 

This is the form of colic produced by the introduction of lead into 
the system, whether in food, by respiration, or cuticular absorption. 
It is a disease which was long known and described before its cause 
was discovered. The discovery was made in Germany, about one 
hundred and thirty years ago, by detecting publicans putting a pre- 
paration of lead into their wines. It is said that the disease used to 
prevail in Devonshire and other places where cider is manufactured, 
in consequence of putting lead into the casks, to render the cider 
sweeter. The disease also prevails in the neighbourhood of smelting 
furnaces and lead mines; indeed, it is even said, in such situations, 
to affect the lower animals, such as poultry, pigs, &c. House paint- 
ers, plumbers, potters, glaziers, and all who are compelled by their 
occupation to handle lead, are subject to this disease, particularly if 
they are not well guarded by personal cleanliness. Sir George Ba- 
ker* was the first who drew the attention of the profession in this 
country to this interesting subject. It must be mentioned, however, 
that cases do occur displaying the same phenomena, course, and ter- 
mination, which have been produced by exposure to cold and damp, 
when there could not be the most remote suspicion of the action of 
lead upon the system. 

Symptoms. — The pain never leaves its principal seat about the 
umbilicus and pit of the stomach ; at first it is dull and remitting, but 
gradually increases to be very severe and constant. The pain, in some 
severe cases, strikes through the back, and patients have told me that 
it resembled a stab through the body ; others have felt as if they 
were cut in two at the umbicilus. In other cases, the pain extends 
to the arms and hands, down the back and pelvis, often affecting the 
lower extremities. The integuments of the abdomen feel retracted 
and hard, and I have seen the strongest men rolling and weeping 
like children. The whole surface sometimes suffers from pains, 
which the patients ascribe to rheumatism ; there are constipation, 
sometimes tenesmus, and occasionally sickness and vomiting. The 
sickness and vomiting are most severe at the height of the paroxysm; 
acrid mucus is sometimes vomited, or bile mixed with mucus, afford- 

* Vide Papers in the 1st and 2d vols, of the Transactions of the London College 
of Physicians. 



PAINTER'S COLIC. 217 

ing temporary relief. [Occasionally there is vomiting from the very 
commencement, and I have even known the disease to be ushered 
In with profuse diarrhoea.] Hiccup sometimes supervenes, together 
with retraction of the testicles. 

It is a matter which strikes every one with astonishment, that, not- 
withstanding the violence of the symptoms, and the excruciating 
sufferings of the patient, the pulse is rarely much affected till the 
disease goes on for some time: in the end, however, it becomes quick 
and small. It has been remarked by some, that the feet and toes are 
occasionally affected, as in gout. 

Spontaneous relief is said to follow a copious discharge of scybalous 
matter, like sheep's dropping, mixed with mucus and considerable 
quantities of blood. Occasionally, it is said, sweating produces a 
crisis. Sometimes the disease produces palsy of the superior ex- 
tremities, and occasionally it terminates in death, which is preceded 
by a loss of sight and hearing, delirium and convulsions. [The para- 
lysis of the arms is in some cases confined to the extensor muscles, 
which, at the same time, shrink and almost disappear; while the 
flexors remain but little if at all impaired.] One attack leads to 
another; that is to say, a predisposition is left. 

Colica pictonum is a most afflicting disease to treat; for, do what 
we will, the patient is seldom relieved under a week, even when 
well managed, and relapses often take place at times when he is 
apparently doing well. He may be pronounced to be in great danger, 
however, when there are delirium, violent spasms, and convulsions. 

Appearances on dissection. — The following is an abstract of the 
appearances found on dissection, in the bodies of a number of indi- 
viduals who died of this affection in the hospital of Beaujbn, under 
the care of M. Kenauldin. Redness, thickness and ulceration of (lie 
mucous membrane of the alimentary canal, and often enlargement of 
the mesenteric glands, corresponding to the inflamed or ulcerated por- 
tions of this membrane. The redness varied from that of bright rose 
even to violet and brown; it was disposed in points, in streaks, and 
in patches, and sometimes occupied an extent of several feet. The 
thickness was variable. The ulcerations were found almost always 
toward tin; termination of the small intestines, near the valve of the 
. which was sometimes destroyed ; and in cases where diarrhoea 
prevailed, ulcerations were found in the colon ; and sometimes they 
were observed in the stomach. They were occasionally deep, and 
numerous; sometimes the stomach and intestines were perforated.* 

[Caa r,nol unfrequenlly occur, and especially those which 

have passed rapidly to a fatal termination, in which no morbid de- 
rangements can be detected. "The mucous membrane/' observes 
Dr. Symonds, •• has been found usually dry, corresponding to the 
character of tin: Btools; but, excepting this, there is no appearance 
that bears any relation to the symptoms. The prevalent opinion in 
the present day is that the disease is of a neuralgic nature. The 
wandering pains and impaired action of tin: voluntary muscles, the 
ional spasm of the org piration, and the termination of 

• Vide Roche and Sanson, toI. I. j> ' i antbon Inform as ibatM.Be> 

nanldin bad IWO liuiulml and seventy live ca* I daring ihc years 1891-98-23. 

iy 



218 PAINTER'S COLIC. 

the disease in convulsions, apoplexy and palsy, intimate that the 
poison acts directly upon the nervous system, and more especially on 
the spinal marrow."] 

Treatment. — The nature and seat of this disease are imperfectly 
known ; but there can be no donbt, from the symptoms during life, 
and the appearances found on dissection, that it is probably seated, 
in the first instance, in the nervous system, and that we have to dread 
inflammation of the mucous membrane of the stomach and bowels. 
I can speak confidently, from experience, of the good effects of local 
bleeding by repeated cuppings and leechings on the abdomen and 
flanks. Many entertain an unaccountable dread of opening a vein 
in these cases, perhaps from prejudices of education : since I have 
seen the above account of the appearances on dissection, my objec- 
tions to it are so far removed, that I shall hereafter try venesection 
on proper occasions. 

The remedies of the first importance are calomel and opium, given 
in pills containing four or five grains of each, repeated at short inter- 
vals, so as to affect the system as speedily as possible. This reme- 
dial means has been strongly recommended by my friend Dr. Mus- 
grave, of the island of Antigua. 

One of the most severe cases of colica pictonum, that ever fell under 
my care, occurred since the publication of the 1st edition. The patient 
was an apothecary's shop-man, aged 32, previous health good, and 
habits regular. The attack appeared to be owing to bathing the feet 
several times in a solution of acetate of lead, to suppress a fetid per- 
spiration. In this case the paroxysms of pain were very distressing; 
the abdomen hard and distended; the features sharp and anxious, 
with hiccup and vomiting. The pulse did not exceed 80 till after 
venesection had been twice repeated, and large doses of calomel and 
opium administered, when it rose to 110. Venesection produced no 
relief; tobacco injections, fomentations, &c, were used in vain. The 
symptoms, however, became much mitigated after the third large dose 
of calomel and opium, conjoined with croton oil. He relapsed cer- 
tainly, but was convalescent on the third day, and recovered pro- 
gressively. 

The bowels are extremely torpid in this disease, therefore common 
remedies must not be depended on ; croton oil in doses of two, four, 
and six drops, must be given repeatedly at proper intervals, still con- 
tinuing the calomel and opium. Turpentine is to be exhibited, both 
by the mouth and by injections. Large injections are to be adminis- 
tered; sometimes stimulating, at others unstimulating. Hot fomenta- 
tions are to be applied ; contra-irritation, when the disease is on the 
decline, which is to be for some time persevered in during the con- 
valescence. The nitrate of silver has been strongly recommended in 
three, five and six grain doses, in pill, three times a-day.* Dr. Per- 
cival gave fifteen grains of the sulphate of alum every fourth, fifth, 
or sixth hour; and he assures us the third dose seldom failed to alle- 
viate the pain.t 

It is proper to mention, that Dr. Reynolds has the credit of being 

* By Dr. Robert. 5ih vol. Med. Trans, 
t Vide 2d vol. Ed. Med. Essays. 



[PAINTER'S COLIC] 219 

the first who proved the powerful influence of opium over the mor- 
bid action produced in the system by lead. 

[The treatment which has proved most successful in Philadelphia, 
(where, from the extensive white-lead works, colica pictonum is a 
common disease,) is the following, for which, however, I disclaim 
any originality, having adopted it for fifteen years past, and applied 
it to a great number of cases both in public and private practice. 

Free bleeding from the arm, in the first stage of the malady, can 
seldom be dispensed with; after which the main object is to touch, 
the gums with mercury, in order to relieve the bowels. Without 
this precaution the disease will often prove fatal ; and even when the 
patient survives, paralysis and a crippled constitution are almost sure 
to follow. To bring on the mercurial impression, and at the same 
time to relieve the pain, I give ten grains of calomel and two of 
opium, repeating this dose every hour or two according to the vio- 
lence of the attack. Simultaneously a blister should be applied 
over the abdomen, which, as soon as drawn, is to be dressed with 
mercurial ointment It may be even necessary to rub in the oint- 
ment on the thighs and arms. After the patient has taken four 
or five doses of the calomel and opium, his stomach, if retentive, 
should be plied with castor oil at such intervals as it will bear. If 
the stomach rejects all medicine, very large injections must be re- 
sorted to. These should consist of the usual drastic cathartics: but 
I have in several cases found copious injections o( cold water to in- 
duce the peristaltic action, when every thing else has been unavailing. 

The bowels, however, will rarely yield, in any considerable degree, 
until the mercury takes effect, when purging becomes at once pro- 
fuse, to tin; great relief of all the symptoms. 

I have never seen a death from colica pictonum when this plan of 
treatment has been followed from the beginning. 

M. Gendrin has published some observations on sulphuric acid as 
a prophylactic against lead colic. The acid is given in the form of 
lemonade, and is said to have proved eminently etlieacious in the 
itories.*] 

[•Dr. : Birmingham, has published the following formpla for propar- 

-<'/-. Takeol treacle 15 lbs; bruised ginger, fib.; 
twelve gallons; yeasi I quart; bicarbonate "i Boda jounce; sulphuric acid 
(oil of vitriol) 1A o .'in. Boil the ginger in two gallons of watei ; add, 

tin; treacle and the remainder of the water, hot. When nearly cold, transfei ii to a 
cask, ami ad ■ fermentation. When this has neai iv ceased, add the! 

sulphuric acid, previously diluted with eight times ii- quantity of water, and then 
add the bicarbonate of soda, dissolved in <>n<- qnarl of water. Close up the cask, 

ami iii lb r four days On- beer will be fil for use. As ; lous fermentation 

. particularly In 1 • • * i weather, new supplies should be prepared as 
required. 

h B m adds that this plan "was carried Into effect in the summer of 1841, 
and tfa [ft Ing, as, although during several a eeks after 

the addition • >( the sulphuric acid to the treacle beverage, little advantage seemed 

to be derived, vei the ca •■• of lead colic beci gradually less frequent ; and since 

n, or during s period ol fifteen months, noi a single case <>r lead 
colic b igthe peo| le. We b i I this prophylactic plan ; 

m, u will be well de i 1 1 Ing of a full trial in 
any large lead factory.] 



ILEUS. 



ILEUS. 



The attack comes on exactly like a common colic : vomiting takes 
place, which subsequently becomes incessant; sometimes even fecu- 
lent matter is discharged by the mouth, and the abdomen is much 
distended. [In fact, as Dr. Watson has remarked, " the term ileus 
is applied to those cases whether inflammatory or not, in which, by 
an inverted action of the intestines, their contents are carried, in a 
retrograde course into the stomach, and thence out of the body by 
vomiting."] The symptoms vary much in intensity. Sometimes 
the pain is severe, amounting to tormina; at others it is slight. In 
some cases the febrile symptoms run high, in others, there is no fever. 
In this case, and even in common colic, the abdomen should be mi- 
nutely examined with the hand, to ascertain whether or not a hernia 
exists; for I have seen two or three instances where much valuable 
time was lost, in consequence of mistaking a case of hernia for colic. 

Appearances on dissection and pathological remarks. — Con- 
siderable dilatation of one part of the intestine is generally seen, 
while the continuous part is contracted ; the parts above the con- 
tracted portion, are distended with fluid and flatus. Sometimes the 
intestine is of a livid colour, inflamed and even mortified. At other 
times there are marks of peritoneal inflammation; and on some oc- 
casions, gangrene, without peritonitis. 

In treating of the nature and seat of this disease in the 1st edition, 
opinions similar to those of Dr. Abercrombie were advanced, viz.: 
that the disease probably consists of "a paralysis of the muscular 
coat of a part of the intestinal tube, which leads to great dilatation ; 
while the continuous portion of the bowel is contracted, which pro- 
duces a temporary obstruction." "But, (it was added,) there is 
much ambiguity on this subject." Since that period I have thought 
frequently on the disease, and, from an interesting conversation with 
Dr. William Stokes of Dublin, one of the most ardent and accurate 
pathologists in this country, I have become convinced that Dr. Aber- 
crombie's views are erroneous. 

In fatal cases of ileus, the bowel has been generally found in two 
opposite conditions — one part contracted like a cord, and another 
part above much dilated. The point to be determined is, which of 
these is the primary seat of the affection? Dr. Abercrombie thinks 
it is the dilated portion, and that "the doctrine of spasm, as applied 
to this subject, must be admitted to be entirely gratuitous; and 
we must proceed upon fuels, not upon hypothesis, if we would 
endeavour to throw any light upon this important pathological 
question."* In the last sentiment I most cordially agree; and as the 
author has substituted hypothesis for facts, I shall shortly state several 
reasons for dissent. 

1st. Dr. A. avers that u the collapsed state of the intestine, in 
which it assumes the form of a cord, appears to be the natural 
state of healthy intestine" " That in a case of ileus, the dis- 

* Researches on the Bowels, p. 134. 



ILEUS. 221 

tended part is the real seat of the disease; and that the contracted 
part is not contracted by spasm, but is merely collapsed because it 
is empty, its muscular action being unimpaired." — P. 136. 

We submit, that the eord-like contraction is not the natural state 
of intestine. If it were the natural condition of parts, it would be 
always seen on dissection, when the bowels are unaffected by dis- 
ease, whereas, it is avowedly rare, and, according to our observa- 
tions, is only seen when the intestinal tube is in a morbid state. 
This appears to be satisfactorily proved by Andral, Billard, and 
others. We have examined the bowels of animals, opened during 
life, and on no occasion found the tube in the state which is asserted 
by Dr. Abercrombie to be natural. 

2d. It appears to ns that Dr. Abercrombie does not connect ileus 
with any known pathological state. He considers ileus to be a great 
and uniform distension of a part of the intestine, with loss of power 
of its muscular fibres. In short, he supposes the distended intestine 
to be in the state of paralysis, and that this is the primary disease. 
He states, also, that the " usual progress of the disease is into inflam- 
mation and its consequences." — P. 13S. 

Dr. Abercrombie cautiously avoids the term "paralysis;" but it 
must be admitted, that loss of muscular power proceeds either from 
paralysis or inflammation in the part: if paralysis, it is the opposite 
of the state of irritation, for nervation is abstracted, not added; if 
inflammation, then Dr. Abercrombie is wrong; but in neither case 
can he be correct. 

It will be observed, also, that he does not denominate the cord-like 
state of the intestine "contracted," which he ought, but "collapsed," 
which term he ought not to have employed, because it conveys any 
thing but a correct notion of the actual state of parts. 

3d. When we speak of a muscular organ such as the intestine, 
we must admit spasm to be possible, nay, probable; and we cannot, 
therefore, ad mil the doctrine of spasm, as applied to this subject, to 
be "entirely gratuitous." No one denies the muscularity of the 
intestines, and that they are capable of contraction, which implies an 
a of nervation. It' Dr. Abercrombie's idea were correct, the 
bladder should never fill, nor the heart, nor the fieccs pass through 
the intestine, unless muscular fibre could be stimulated to dilute. 
Hut it will be proper to allow Dr. Abercrombie to speak for himself: 
'• If we suppose, then, that a considerable tract of the canal is in a 
collapsed state, and that ;i mass of alimentary matter is propelled 
into it by the contraction of the parts above, the series of actions 
which will take place, will probably be the following: When a por- 
tion, which we shall call No. I , is propelling its contents into a portion 

of No. -'. the force exerted must be such as both to propel these con- 
tents, and also to overcome the tonic contraction of No. 2. The 
portion N ». I then contracts in its turn, and propels the niattcr into 

this into No. 1. and so on."— P. 136. 

It will lie readily Been, on looking at the parts, that the empty 

intestine is not m .a stale of u tonie contraction" as Dr. \. asserts, 
and that it offers no resistance to the alimentary mass, which is 



2-22 ILEUS. 

propelled onward by the contraction of the superior portion of in- 
testine. 

4th. If the dilated intestine usually passes into inflammation and 
gangrene, and its seat be in the muscular coat, its first stage must be 
one of irritation. The effect of irritation on muscular fibre is, to 
suddenly and powerfully contract it. The parts may become dilated 
afterwards, but the first effect will be contraction ; and the contracted, 
of course, the diseased portion. It follows, then, as a necessary con- 
sequence, that if it be spasm, the contracted is the diseased portion; 
or if, according to Dr. Abercrombie, it be disease of the muscular 
fibre, still, in the first instance, the same will occur. 

Ileus, according to Dr. Abercrombie, is either a paralysis, or an 
irritation of the muscular fibres of the intestine, usually terminating 
in inflammation and gangrene. Could any two things be more op- 
posite? If it be a paralysis, it is either general or local. It is not 
general, because all the symptoms are those of violently increased 
action, colic, vomiting, spasms of the abdominal muscles, and 
paroxysms of tormina! Tormina and loss of power together? If 
it be local, it is, at all events, accompanied by increased muscular 
action — spasm. 

If the primary diseased action be connected with irritation, as we 
imagine, the first effect will be to contract the parts. 

Lastly, It may be asked, does the treatment coincide with the 
doctrine of paralysis, or that of irritation and spasm ? After describ- 
ing the treatment, I shall return to consider this important question. 

Treatment. — The chief attention must be directed to prevent and 
subdue inflammation, and to employ every means to move the bow- 
els. For this purpose, the milder laxatives frequently repeated, 
assisted by tobacco injections, are to be had recourse to. If these 
fail, then we may entertain the question of bleeding, particularly 
if the case be not far advanced, and if there be pain on pressure. 
Leeches may be applied ; but still we must not lose a moment in 
endeavouring to procure stools. Although we may mitigate the 
symptoms by bleeding and leeching, yet we may rest assured that a 
relapse will take place in the course of an hour or two, unless the 
bowels are relieved. Dashing cold water upon the belly has some- 
times succeeded. When the gut is supposed to be obstructed, mer- 
cury, in its pure metallic state, has been recommended to be poured 
into the stomach in considerable quantity, in order to force a pas- 
sage. Once I was present at a dissection, when the obstruction 
existed at about six inches from the termination of the rectum; and 
since then I have met with two cases of ileus, which were produced 
by constriction of long standing of the rectum ; therefore I think, in 
all severe cases of this sort, that a long oesophagus tube should be 
introduced into the rectum, and, if possible, pushed forward into the 
sigmoid flexure of the colon. 

This is one of those diseases in which we frequently succeed in 
procuring passage from the bowels after bleeding, which had pre- 
viously resisted the strongest purgatives; it is also one in which large 
opiates may be advantageously combined with laxatives. Opium 
generally acts by confining the bowels; but in the case now before 



INTUS-SUSCEPTION. 223 

us, it seems to increase rather than diminish the laxative effect of 
medicines. During recovery, it may be advisable to apply contra- 
irritation. 

It has been already asked, if the most improved remedial means 
coincide with Dr. Abercrombie's hypothesis? Bleeding, tobacco 
enemata, full doses of opium, and contra-irritants, to cure a disease 
which is a simple loss of the muscular power of a portion of the in- 
testinal canal? The circumstance cannot be reconciled upon prin- 
ciples of pathology. Much real injury is done to the advancement 
of medical science, by the construction of such distorted theories; 
and I cannot resist quoting a passage from the preface of Dr. Aber- 
crombie's work on the bowels, which bears on the present question. 
Speaking of the circumstances which have retarded the progress of 
medicine, he says, there are two errors committed — the one is the 
"construction of hypothetical theories, or the assumption of prin- 
ciples which are altogether gratuitous and imaginary; the other 
is the deduction of general principles or conclusions from a limited 
number of facts." — P. 8. 



INTUS-SUSCEPTION. 

Intus-susception, generally speaking, is a disease of infancy. 
There are the same symptoms as described in ileus, only that in 
many cases there is violent straining; the patient passing more or 
less bloody mucus with each effort, in some instances exactly re- 
sembling red currant jelly. This, like all other affections, varies 
very much in the symptoms as to violence ; this was well proved in 
two fatal cases occurring in the same family, which fell under my 
immediate notice. They were both male infants at the breast; the 
rail its course in three days; but the symptoms were very 
violent in one case, and very slight in the other. In both, a tumour 
was felt in the left iliac region, at the termination of thirty-six hours, 
which gradually increased in size, till it became as large as an 
Both children strained much at stool, and passed mucus 
tinged wilh blood. I have known the disease terminate fatally in 
thirty hours. 

Appearances on dissection. — We often find partial invaginations 
nail intestines. I scarcely ever open a child without finding 
them; but they are not to be regarded as intus-susceptions, unless 
its are thickened, with marks of obstruction and inflammation. 
At least so I thought when the first edition was written. Since 
then, however, I have become doubtful on this point, having dis- 
covered ulcerations in the intestines at each intus-suscepted put in 
every case which I have had an opportunity of examining. In the 

>ni "!' patients who die of iiitus-suseeptioii, it is the caput 

ccBcum, and a portion of the ii'iim, wineh are commonly forced up 
sending colon aero ithe transverse colon, and sometimes down 

to the sigmoid llexure. In one of the cases to which I have alluded, 



£24 INTESTINAL CONCRETIONS. 

the caput caecum was found in the rectum, very near to the extrem- 
ity of that gut. Could such a transposition have taken place un- 
less there had been some original malformation ? I think not. Upon 
first opening the abdomen, in both cases mentioned above, the intes- 
tines looked displaced and twisted in a strange manner, and the 
caput caecum was missed from its usual position in the right iliac 
region. 

On slitting open the intestine at the point of obstruction, we find 
two mucous surfaces highly inflamed, dark-coloured and thickened, 
and covered with a considerable quantity of effusion of a red colour, 
intermixed with a whitish matter like coagulable lymph. On laying 
open that part of the intestine which is invaginated, we then expose 
to view two serous surfaces, which are also found in a state of in- 
flammation, with exudation of lymph and adhesion. 

Treatment. — The same plan is to be had recourse to as in ileus, 
only this is altogether a more hopeless case; we are to be more 
guarded in using strong purgatives, lest we increase the torments of 
the poor little sufferers. It is said that a natural cure sometimes 
takes place by a spontaneous separation of the intus-suscepted por- 
tion of gut; and in every extensive collection, a preparation or two 
of this kind is exhibited. 



INTESTINAL CONCRETIONS. 

Some remarkable cases of this kind are on record; but man is not 
nearly so liable to the complaint as some of the lower animals. A 
case is published in the eighth volume of the Edinburgh Medical 
Communications, by Dr. Fitzgerald. The patient, a lady, suffered 
extreme pain in the hypogastric region, the back, and os sacrum, for 
eighteen months; during the last three of which she could not leave 
her bed, except to be put into the hot bath, which afforded only 
temporary relief. One day, after receiving an injection, a large, hard, 
calcareous ball, of an oval figure, was discharged. It exceeded in 
size an ordinary orange, and was so solid, that it required a stroke of 
a hammer to break it. It weighed eight ounces and three drachms. 

Sometimes there are several of these concretions; in that case, they 
may be heard rattling upon percussing the abdomen. Many curious 
instances of this affection are related in the Philosophical Transac- 
tions. The late Dr. Marcet wrote an essay on the chemical history 
and medical treatment of calculous disorders, wherein notice is also 
taken of several interesting cases, to which, as well as to the first 
volume of Good's Study of Medicine, I must refer the reader. 

It is alleged that the inordinate use of chalk and of magnesia in 
dyspeptic and calculous complaints, leads to the formation of these 
substances. Mason Good mentions a case of a lady whom he had 
once attended; she "laboured under a most painful constipation, till 
a large mass of what may be called intestinal mortar, was removed 
by a scoop from the rectum."— P. 297, vol. 1st. 



PROLAPSUS ANI. 035 

[These concretions are variable in their origin and composition, 
and possess much interest on account of their frequent occurrence. 
They, for the most part, form around foreign substances which have 
been received into the bowels, as fruit-stones, seeds, pieces of bone, 
&.C.; but there are others which are derived from no perceptible nu- 
cleus, but consist of impacted faeces, which, from long retention and the 
deprivation of moisture, assume an earthy hardness, and can only 
be removed by mechanical means, after they have become lodged in 
the pouch of the rectum. 

Whatever may be the chemical character of the substances, the 
attendant symptoms are much alike and for the most part very ob- 
scure, excepting in emaciated persons, in whom the calculi are readily 
detected under the fingers, through the parietes of the abdomen, but 
for the most part in the caecum or right ascending colon. They will 
sometimes remain lodged in these places for years, giving rise to no 
very obvious symptoms other than depraved digestion, and general 
debility and loss of flesh. Together with these symptoms I have seen 
the most extraordinary nervous irritation, with erratic spasms or 
cramps, at one time in the intestines themselves, and then passing 
in an instant to the voluntary muscles of any and every part of the 
body, until life has yielded to protracted suffering which nothing but 
anodynes could even mitigate. And yet, in the instance to which I 
refer, the concretions, when examined after death, were little else 
than dry impacted faeces, which the bowels, owing to a perfeet torpor, 
were unable to expel ; nor was it possible by medicines to force them 
further than the rectum, from which they had to be removed by a 
curved, scoop-like spatula made for the purpose.] 

Treatment. — If the nature of the disease be discovered, large 
mucilaginous injections ought to be frequently administered, alter- 
nately with those of an anodyne nature, to allay irritation. Blisters 
and leeches may sometimes be necessary to allay internal pain, and 
moderate any inflammation that may arise. If sneh substances can 
be felt through the parietes of the abdomen, as is alleged, it may, 
perhaps, t>" possible to push them on, daily, in the course of the 
bowels towards the rectum. In females, I can conceive it to lie very 
10 break them down when they arrive in the rectum •, and con- 
siderable assistance will be afforded by introducing one or two fingers 
into the vagina. The warm bath is not to be neglected. 



PROLAPSUS ANI. 

Pjv this term is understood the protrusion of a portion of the mu- 
cous membrane of the rectum, tip: sphincter contracting forcibly, and 
producitig a temporary stricture. Prolapsus ani depends either upon 
a temporary want of power on the part of the sphincter ani, or some 
viol. -lit irritation in the rectum, producing great straining, which, in 
medical language, is termed tenesmus, during which the mucous 
membrane is protruded. Ii is now much more rare than formerly, 
owing to greater attention paid to the bowels of children, who are 



226 CONSTRICTION OF THE RECTUM. 

generally the subjects of this complaint. Formerly a pernicious cus- 
tom prevailed of endeavouring to produce a stool, by making children 
sit upon a pot containing a little boiling water, instead of giving them 
physic. 

Symptoms. — The protrusion takes place when tiie child is bearing 
down at stool, or making water ; it begins to cry most violently from 
pain in the part affected, and the protrusion takes place. On making 
an examination, the mucous membrane is found of a dark red colour; 
the protruded portion is of various sizes, sometimes as large as a 
small orange. Formerly a piece of scarlet cloth was applied to the 
part by the women, under the idea that it would be thus reduced ; 
but now almost every nurse knows how it should be reduced. The 
child being placed on the back, gentle pressure is to be applied to 
the protruded portion of gut, by the thumbs of the operator, which 
have been previously dipped in oil. If the protrusion has continued 
so long as to cause violent inflammation, rendering the return of the 
intestine impossible, leeches may be applied with great advantage. 
The case of an adult recently came under my care in which the gut 
remained exposed for nearly forty-eight hours, and only became 
manageable after free leeching. Soft poultices are important adju- 
vants. [Either purging or constipation tends to this displacement, 
whence the importance of regulating the bowels. If they be con- 
fined, free injections of mucilage will act gently and effectually ; but 
if the opposite state exists, small injections of the same kind, with the 
addition of a little sulphate of zinc, will tend to correct the evil : 
so, also, injections of cold water, and frequent ablutions with the 
latter around the region of the anus.] 

People advanced in age are sometimes affected with prolapsus 
ani ; it frequently depends upon diseases of the urinary organs, as 
well as of the bowels. The parts are occasionally so much relaxed 
as to require the use of a bougie, and sometimes of a bandage; or a 
more serious and painful surgical operation is necessary. 



CONSTRICTION OF THE RECTUM. 

Little need be said respecting constriction of the rectum in a 
work on the practice of physic ; indeed, it is introduced only for the 
purpose of drawing the attention of physicians to the subject. I 
have seen several cases within these few years, in which many 
dangerous attacks of constipation might have been avoided, had the 
disease in the rectum been early discovered. This affection may be 
suspected in every case of habitual constipation, particularly in those 
instances where the patients have to strain long at stool before the 
least passage can be procured, which is followed by pain in the part, 
and frequent attacks of piles. Laxative medicines afford only tem- 
porary relief, and when too powerful, I have seen symptoms of ileus 
induced. The only remedy is to be found in the frequent intro- 
duction of the bougie. I have been lately consulted in two instances 
where symptoms of ileus were occasioned by this affection ; both 
patients were permanently cured by dilating the stricture. 



CHAPTER VI. 



INTESTINAL WORMS. 

There are principally three kinds of worms which infest the 
intestinal tube,— the lumbricus, tenia, and oxyuris.* 

Is*. Jiscai'is lumbricoides. — It resembles the common earth worm, 
in general appearance, varying in length from three to twelve inches, 
and having a reddish-brown colour, and may exist in considerable 
numbers ; instances are on record of upwards of fifty having been 
voided. Lumbrici lodge in the small intestines, and occasionally in 
the stomach, and are therefore frequently vomited, and even escape 
from the nostrils. — They often excite little uneasiness, but in some 
cases they create griping and considerable constitutional suffering. 

2d. Tenia or Tape Worm. — Of this genus there are two species, 
the tenia solium, and tenia vulgaris^ The first, as its name im- 
ports, is solitary ; the second may exist in families. They generally 
take up their quarters in the higher parts of the intestines; for the 
purpose, as is supposed, of feeding on the chyle. Tape worms 
appear to be composed of a great number of pieces or animals 
joined together by articulations. In the tenia solium these articu- 
lations are long and narrow ; while, in the other kind, they are short 
and broad. The solitary tape worm lias been known to measure 
between thirty and forty feet; and one extraordinary worm is men- 
tioned by Or. Sibbargaarde, of Copenhagen, which measured thirty- 
eight yards. The tenia vulgaris measures generally from three to 

3d. The Oxyuris, or ascaris vermicularia thread-worm, generally 
es in the rectum, enveloped in mucus; it is the smallest, being 
only like threads, from an eighth to a quarter and half an inch in 
length. 

■\th. Tricocephalus dispar., or long thread-worm. — This also some- 
n iip's collects in great numbers in the small intestines. The body is 
round, thickest posteriorly, and slender as a thread anteriorly, and 
attains the length of one or two inches. [It chielly inhabits the 
caecum, hut is less frequently met with than the other species.] 

Worms chietly exist in children and sickly adults, and are gene- 
rally attributed to some diseased condition of the secretions in the 
alimentary canal. I believe the inhabitants of Great Britain suffer 
less from them than those of any other nation. Mr. Marshall, 

• Th< r I another kind of worm occasionally met with, the trichnris, trai of which 

I -hall not treat, being more an object for the natural historian. Another eMeies, 

Ibeo, lias lately bees <ii jcovered in my collection by Captain Brown, 

an Ingenious naturalist, and described ■< the ozynria anyulata in an excellent little 

Warms, by William Rhind. E q., surgeon. 

t [Called also Tenia lata, and Bothrioceptialaa latus by naturalists.] 



228 [INTESTINAL WORMS] 

deputy inspector-general of hospitals, informs me that Europeans 
are very liable to lumbricoides in India, and perhaps Africans are 
even more so. Few post-mortem examinations are made without 
discovering them. One negro passed forty lumbrici in one day ; in 
seven days he passed altogether two hundred. 

It is an interesting point to determine, whether worms are pro- 
duced in the intestinal tube itself, or are generated from ova or 
animalcules accidentally swallowed with the ingesta. Various opin- 
ions have been maintained in support of each view. A case, how- 
ever, occurred in the sessions 1S34-5, in the veterinary school of 
Edinburgh, that convinced my mind of the truth of the former 
theory. A horse, having died rather suddenly, was minutely exa- 
mined by Mr. Dick and his pupils, to discover the cause of death. 
Several small slender red worms, (the strongylus armatus,) were 
discovered in the intestinal tube. On examining the mucous mem- 
brane, the distinct follicles were observed to be very numerous, 
large, and elevated. On the surface of some of them, a dark-coloured 
spot was seen, which, on close examination, was found to be a 
hole, communicating with the interior follicles; in others it was 
wanting. Incisions were cautiously made, to expose the contents of 
the follicles that were without the opening, in each of which a small 
red worm, strongylus armatus, was found coiled up like a snake in 
its egg; the others were empty, but retained the impression made by 
their late occupants, and a circular hole in the centre through which 
they had made their escape. 

[The following facts and arguments from the pen of Dr. Stokes, of 
Dublin, are so full of instruction on this interesting question, that I 
need offer no apology for introducing them in this place. " There is 
no direct evidence to prove that these animals have been introduced 
into the body from without, either in the form of ova, or in a state 
of perfect development. — First, it appears that the worms which 
have been found in man and animals, have a peculiar structure and 
organization, differing materially from the worms which inhabit the 
external world. — In the next place, we find that the worms of cer- 
tain animals present peculiarities differing from those of the same 
species [genus] in others. Not that every animal has its peculiar 
worms; for the lumbricoides and small ascarides of man, are found 
to exist in various animals, both carnivorous and graminivorous. — 
We find worms, moreover, in the brain, heart, kidneys and spleen ; 
and there are certain species of worms which occur only in the same 
organs, and are never met with in any other situation. — It would be 
ideal and absurd to say that in the case of worms found in the sub- 
stance of the viscera, that they had been introduced from without, 
or came from the intestinal canal. The distoma hepaticum, which 
is found in the liver and gall-bladder, might be supposed to arrive at 
those situations by passing along the ductus communis choledochus; 
but, in the various cases in which it has been found, it has never 
been detected in the intestinal canal ; and this, I think, would not 
have been the case if the digestive tube had been its original situ- 
ation."* And lastly, without pursuing this subject further, we may 

* Lectures on the Theory and Practice of Physic, Dr. Bell's edit., vol. ii, p. 499. 



INTESTINAL WORMS. 22^ 

adduce the fact, that worms have been found in the intestines both 
of men and animals, and in those of birds which had just broken the 
shell.] 

Worms frequently produce emaciation, swelled and tense abdo- 
men, gnawing and slight burning pain in the stomach and bowels; 
irregular appetite; a pale, sickly countenance; foul tongue; fetid 
breath ; irritation and inflammation of the nostrils, occasioning great 
itching and desire to pick the nose ; occasional feverishness, particu- 
larly at night, producing restlessness and want of sleep. But none 
of these symptoms, nor all of them conjoined, point out the positive 
existence of worms, because they may be produced by any irritation 
or sub-acute inflammation in the mucous membrane ; and it is too 
much the custom for medical men to conclude that a child has worms 
if it be dull, look pale, and is observed with its fingers frequently in 
the nose. Besides these symptoms, worms occasionally produce 
violent colicky affections, with vomiting and purging, sometimes of 
blood; and I believe ulceration of the bowels, and even peritonitis, 
may be excited by this irritation. More rarely, cerebral symptoms, 
and even epileptic convulsions take place. Children who are trou- 
bled with worms, often awake suddenly, screaming; and frequently 
are observed to grind their teeth. 

Treatment. — The first thing to be done, is to endeavour to repair 
the digestive function, and, at the same time, we must institute an 
exterminating war against all such filthy intruders, by means of a 
class of medicines called anthelmintics. It is curious, however, that 
the remedy which appears to succeed in one or two cases, will dis- 
appoint our expectations in a number of others. Anthelmintics 
naturally divide themselves into two classes: one which operates 
mechanically, namely, ordinary purgatives, common oils, sulphur, 
sea-salt, tin-filings, cowhage; another, which has a peculiar poison- 
ous effect on the animal, as oil of turpentine, hellebore, male fern, 
tobacco, rue ; calomel and other mercurial preparations. Of all these, 
oil of turpentine, calomel, and wormseed-oil, jalap, and the cowhage, 
have been most successful. It deserves to be mentioned, that tur- 
pentine, in doses of from one to two ounces, is the only remedy 
which has hitherto been found generally successful in destroying the 
i. It has been mentioned to me, however, that a decoction of 
the root of the pomegranate tree, is fully as successful. When tur- 
pentine is given by the mouth, care should be taken to have the 
I o ...Is previously well opened, so that it may not be detained in the 
int. si in. s. The condition of the stools must be watched, which, 
together with Other symptoms, treated of under the head, " Usual 
iplaints of Children," will generally announce whether there be 
any considerable irritation or inflammation in the mucous membrane* 

Should BUCh symptoms exist, the application of leeches, or of a con- 
tra-irritant, may be Docossary, 

I Ascarides are most effectually attacked by injections: one of the 
best of these is made by dissolving a drachm of aloes in half a pint 
of warm water, and administering it at a single operation. Bnemata 

Of simple ohve. oil, or spirits of turpentine, mixed with any mucilage, 
answers the same purpose. 
20 



230 [INTESTINAL WORMS.] 

Of all the intestinal worms, however, the taenia or tape-worm is 
the most intractable; for it often foils all our devices for its expul- 
sion, and continues from year to year to harass its unfortunate vic- 
tim. The usual modes of treatment may be summed up in the fol- 
lowing extracts from an essay by Dr. Wawruch, of Vienna, in which 
city this disease appears to be of very frequent occurrence. As the 
plan here proposed was tried in no less than 206 cases, the results 
possess great practical value. 

As a preparatory step, all the patients took a purgative combined 
with a portion of sal almoniac; this was repeated on four or five 
consecutive days, during which no food was taken but weak broth. 
"In eight cases the worm was expelled by the mere effect of con- 
tinued abstinence. The anthelmintic remedies employed, were castor 
oil and the powdered root of the male fern. From one to two table- 
spoonfuls of the oil was given as a dose, alternately with one or two 
drachms of the powder twice or thrice a day. Enemata of oil and 
milk were frequently thrown up to attract the worm towards the 
large intestine. The drastic purge employed was composed of equal 
parts of calomel, gamboge and sugar, from two to eight grains of 
each for a dose. In many cases a single dose brought the worm 
away: but, in others, three or six doses were requisite. In eight 
cases, as has been already remarked, it was expelled by the mere 
effect of purges; in thirteen cases, by the anthelmintics alone ; in 
eleven, by the first, in fourteen, by the second, and in fifteen cases, by 
the third drastic purge ; and, generally speaking, it came away within 
one to twelve hours after the last drastic."* Dr. Wawruch adds, 
what the experience of every extensive practitioner will confirm, 
that the taenia is not always solitary ; for he found nine cases in which 
there were two worms ; two cases of three worms ; and one example 
of four worms, which last remained uncured. Twenty-six of his 
cases relapsed ; but he considers the patient as cured, if ten or twelve 
weeks pass without a re-appearance of the worm. 

Tape-worm is certainly a very unfrequent disease in the United 
States, even in our hospitals. The following case, which occurred in 
my private practice, is very remarkable, not only for its duration, but 
for the resistance of every plan of treatment; and with the consent 
of the patient, who is a merchant of this city, I take this occasion to 
place it on record; merely premising that I first submitted the facts 
(which were pronounced correct in all their details) to his inspection. 
Mr. T. T., aged about 40 years, of a healthy constitution, was 
attacked early in August, 1835, with inflammation of the liver 
complicated with enteritis. The late Dr. Joseph Parrish, Dr. Isaac 
Parrish and myself, attended him throughout his disease, which 
was in every respect one of the most violent I have ever known to 
terminate favourably. It did so, however, and without remarking 
upon the treatment, which embraced the usual active course in such 
an emergency, we had the pleasure to see our patient leave his sick 
chamber towards the close of September; his illness having con- 
tinued a little short of two months. Towards the end of the same 

* Braithwaite's Retrospect, Part iv. p. 26. 



[INTESTINAL WORMS] 231 

year, or about six months after the first attack, he called to show me 
several single joints of tape-worm, which he informed me were daily 
and almost hourly coming from him in that form. The striking re- 
semblance which these detached joints bore to gourd-seeds, enabled 
me at once to identify them with the narrow tape-worm, or Tasia 
solium; 9 and I immediately commenced a course of treatment for the 
purpose of destroying it. This was about the commencement of the 
year 1S36. Eight years and a half have since elapsed, yet the de- 
tached joints, with occasional long pieces consisting of many joints, 
have continued to come away daily. Sometimes two or three feet 
of the worm, in other instances, ten feet in length have been voided; 
but without a respite or interruption of more than three consecutive 
days during that long period. I have, on many different occasions, 
inquired of the subject of this malady respecting the average number 
of joints which come from him in the twenty-four hours; and he has 
uniformly assured me that they cannot be less than ten. Taking this 
number, then, as the basis of a calculation for eight years and a-half, 
or 3102 days, and allowing three quarters of an inch for the length 
of each joint, it follows, (and the estimate in my opinion is far within 
bounds,) that this gentleman has already passed one thousand nine 
hundred and thirty-nine feet, or six hundred and forty-six yards of 
tape-worm! What.it will naturally be enquired, has been done to 
destroy such a disgusting parasite? I answer, every thing that the 
books and experience have recommended, or that art and ingenuity 
could devise. Mercury long continued, even to ptyalism; spirits of 
turpentine until it has caused strangury; drastic purgatives until they 
could be tolerated no longer; all the known vegetable and mineral 
anthelmintics; bill all to no purpose; until my patient, finding no 
permanent relief from my treatment, resorted to empirical remedies, 
and took those in such enormous doses as even to astonish the ven- 
ders of them. Hut still the tape-worm makes its daily appearance, 
(1841) in sleeping and in waking, in motion or at rest, in sickness or 
in health. It causes a sense of weight in the epigastric region, and, 
at limes, a gnawing and distress in that part; hut otherwise, u 

iom do obvious symptoms; and the patient, if such I may call 
him, is remarkable for robust health and buoyancy of spirits.] 

[• Thw resemblance i" the gourd-seed led Dr. Ilcbcrden to call this worm by the 
nve name of iMmbriciu eucurbitimu.] 



CHAPTER VII. 

INFLAMMATORY AFFECTIONS OF THE ORGANS CON- 
TAINED WITHIN THE CAVITY OF THE ABDOMEN. 



GENERAL REMARKS. 



Inflammations of the viscera have been distinguished, since the 
time of Boerhaave, by anatomical terms, derived from the name of 
the tissue or organ affected, with the addition of the Greek term, His; 
as gastritis, enteritis, peritonitis, arachnitis, &c. 

It would be an error to suppose that in inflammatory disorders, the 
constitution is always disturbed in proportion to the importance of 
the part affected, and the nature and extent of the diseased action. 
If the organ be a vital one, the disease is certainly attended with 
more danger than if the inflammation attacked an ordinary muscle, 
or the cellular substance to the same extent ; and the disease is much 
more rapid in its progress ; but there are often more pain and a higher 
degree of fever, when the inflammation is situated in the latter tis- 
sues, than in the brain, lungs, &c. 

The constitutional suffering which happens when vital organs are 
affected with inflammation, is attempted to be explained by the term 
sympathy; it is said, in medical language, "the organs sympathize 
with each other." Thus, Dr. Good observes, at page 3S4, vol. ii: 
" When inflammation is seated in the heart, its action becomes ex- 
tremely agitated and irregular. When in the lungs, the heart, possi- 
bly from sympathy, does not seem to allow a free diastole." 

It would afford me much real satisfaction, if the word sympathy 
were always employed in medical writings in a strict pathological 
sense, as I conceive it would be a great step gained in the practice of 
medicine. It is one of those vague terms, too often employed to ex- 
press a great deal more than we actually know, but which explains 
nothing ; and I have frequently seen it highly injurious in practice — 
thus, in inflammation of the stomach and bowels, I have seen the 
most deadly cerebral symptoms lighted up, which were not treated, 
because it was supposed the brain was only sympathizing, not 
really diseased. I have seen the same thing happen in fevers, gout, 
rheumatism, &c. The word sympathy means, strictly speaking, fel- 
low feeling or suffering, and so far the expression is correct, because, 
as has already been explained in a former part of this work, dimi- 
nished action in one organ leads to increased action in another, and 



GENERAL REMARKS, &c. 233 

any thing going wrong with one important function, embarrasses all 
the others. Here it will be remarked, that the organs secondarily 
affected are diseased, inasmuch as they are supplied with too little, 
or with too mnch blood ; or, if the organ affected be excretory, some- 
thing deleterious is retained in the blood, which poisons to a certain 
extent the stream of life, producing embarrassment in all other or- 
gans, although one may show it more than another. Now all this 
shows a fellow suffering — a tendency which one organ has to sym- 
pathize with another. It is to be lamented, however, that this expres- 
sion is too often used in medicine, in the same sense in which it is 
employed in common conversation. 

When inflammation is seated in the lungs, the heart actually does 
suffer, from two causes; first, because the function of respiration is 
impeded, and t he changes produced on the blood in the lungs are 
not properly effected; and secondly, because the circulation through 
the lungs is obstructed. This is certainly accounting for the affection 
of the heart better than by staling that it is '■'■possibly from sympa- 
thy." The same thing happens to the lungs, when the heart is pri- 
marily affected ; there are dyspnoea and cough, not from sympathy in 
its ordinary acceptation, but from an increased or diminished supply 
of arterial blood: and also, by obstruction in the circulation. It may 
be thought by some, that this statement is quite unnecessary ; but it 
is made under a strong sense of its importance, as I have often had 
to witness the baneful effects of the term in actual practice. 

There is another term, which those who are young in the profes- 
sion must be cautious in receiving — it is the word "debility." It 
has already been shown, that oppression and obstructed action are 
generally confounded with debility; and I shall take the liberty to 
make a lew remarks with respect to this term, as applied to the system 
when labouring under inflammation. 

Dr. Mason Good, in noticing inflammation of vital organs, observes 
at the page last quoted, " The debility commences early, because the 
inflammation itself is immediately interfering with the actions essen- 
tial to life." The term debility is usually employed in such cases to 
denote oppression, prostration of strength, inability to perform loco- 
motion; but if the inflammation be quickly removed from any organ 
by bold measnres, the oppression ceases to be felt, and the strength 
is restored by remedies decidedly debilitating. This must ever be 
kept in recollection in treating inflammations in the first and second 
otherwise tin- term will be apt to induce young practitioners 
to follow the fashionable practice of giving bark, wine, and animal 
food, in cases m which they ought lo bleed. 

It must !"• recollected that inflammations arc not always acute; 
perhaps they occur mni'i! frequently in a sub-acute or chronic form. 

The term "acute inflammation,'"' is employed to express the 
highest degree of this diseased action, which arises suddenly, advances 
through us course with rapidity, and, ii do) properly treated, icrmi- 
nates in a few days, by altering the structure "i the part affected so 
much as to render it incapable <>i supporting life. 

The term " sub-f/rn/r in /la in mat 'inn,'" is employed to denote a 
milder degree of inflammation than the former; it arises more insidi- 

80* 



2S4 ENTERITIC INFLAMMATIONS. 

ously, is less severe, and if left to itself, does not destroy the structure 
of the part affected till the second or third week. 

In both these cases, we have the combination of symptoms denomi- 
nated fever, which is higher, generally speaking, in the former than 
in the latter. 

The term "chronic inflammation'" is employed to express a dis- 
eased state which follows an acute inflammation that has been partly 
subdued, as we see sometimes in the tunica conjunctiva of the eye. 
This term is likewise used to signify an inflammation which begins 
and advances slowly and irregularly. The patient passes restless 
nights, with thirst, and a dry burning sensation of the hands and feet, 
while in the course of the day the extremities can scarcely be kept in 
comfortable heat ; although he is always complaining, yet there is no 
severe general commotion during the day : he is able to sit up, to 
take exercise, and even for some time to go through his ordinary 
duties. His restless nights are too generally attributed to indigestion, 
proceeding from something which he has eaten or drank — to an irre- 
gular state of the bowels — want of exercise, or to something which 
had affected his mind; when, perhaps, the substance of the brain 
itself is undergoing slow destruction. In such cases, the common 
routine practitioner will be found prescribing his tonics, diaphoretics, 
diuretics, or blue pill, always treating some symptom, the actual dis- 
ease being hid by an impenetrable cloud from the senses. At length 
the structure of the part becomes more and more destroyed, till all 
the symptoms called hectic are fairly established, or the patient be- 
comes comatose. 

These observations naturally lead me to notice other points in 
pathology. It is surprising to find how completely a vital organ may 
be altered in structure, without producing external signs or symptoms 
of corresponding violence, provided the diseased action has gone on 
very slowly. Another circumstance to be attended to is, that one 
individual, from peculiarity of constitution, will be destroyed by the 
tenth part of an organic lesion which a great many others may sur- 
vive for years, never certainly being entirely well, but able to transact 
their ordinary business. 

The consideration of these circumstances, ought to induce us, in 
our treatment of diseases, to go on steadily, guided, as far as possible, 
by the pathological condition of the body, at the time, without refer- 
ence to accidental symptoms. 

When treating of the congestive form of fevers, it was mentioned 
that inflammatory action might go on concealed under severe con- 
gestions. The same observations are equally applicable to purely 
inflammatory diseases. 



ENTERITIC INFLAMMATIONS. 

Under this title I shall treat, 1*/, Of peritonitis. 2d. Of inflamma- 
tion of the mucous membrane of the stomach. 3d. Of inflammation 



PERITONITIS. 235 

of the mucous membrane of the bowels, which will include diarrhoea, 
the bowel complaints of children, tabes mesenterica, dysentery, and 
cholera. 4th. Inflammation of the muscular and cellular tissues. 
5th. Scirrhus of the stomach and intestines. 



PERITONITIS. 

I shall, in the first place, treat of inflammation of the peritoneum 
in the ordinary state of the system ; 2d, peritonitis after delivery ; 3d, 
a modification of peritonitis after delivery, the consequence of in- 
flammation of the substance of the uterus, or of the uterine vessels 
and absorbents; and lastly, of the chronic form of the disease. 

Cullen, by dividing peritonitis into three varieties, has been guilty 
of a great error, because no one can tell whether it is the peritoneum 
lining the cavity of the abdomen, or that covering the bowels, omen- 
tum, or mesentery, which is inflamed. Although he insists much on 
the propriety of this division, yet he observes, " it is not proposed, 
however, to treat of them here, because it is very difficult to say by 
what means they are always to be known; and further, because 
when known, they do not require any remedies besides those of in- 
flammation in general." 

Although peritonitis may take place most extensively, even to a 
fatal termination, without affecting the subjacent tissues, yet it is rare 
to see a case of inflammation of the muscular coat of the intestines 
terminate fatally, without finding the peritoneum more or less in- 
flamed also. 

Symptoms. — Like other acute affections, peritonitis commences 
with a rigor or chilliness, followed by reaction; occasionally, how- 
ever, as in oiher diseases, peritonitis makes its approach in the most 
insidious manner. 

The pain dillers very much in its extent and severity, being 
sometimes BO slight as scarcely to be complained of throughout the 
whole course of the disease; in others, so severe that the patient is 
to COUgh or turn himself, and he complains even of the weight 
of the bed-clothes. The pain is commonly described as being acute 
tenderness rather than pain; it is sometimes so confined in extent, 
that (he lips of i he fingers can cover the part affected. The uneasi- 
imelimes commences in one part of the abdomen, sometimes 
in another. Generally ii is fust fell in one of the hypogastric regions; 
ii does not, however, continue fixed and confined to one spot, but 
frequently spreads quickly over the whole abdomen. Before death, 
all line a iddenly subsides, which is apt to impose 

Upon the inexperienced ; but the pain, on other occasions, continues 
to (he l.tst, and this is produced, I apprehend, by the extension of the 
inflammation. Tumefaction and tension of the abdomen occur early; 
in the first stage, u is produced by tympanitis, but late in the disease, 
the effusion produces distension. The purse is not to be depended 
upon, as u v.tnes much m different cases ; sometimes it is full, strong, 
and quick, beating 120 or L30 in the minute; at other times it is 
strong and slow, sometimes weak and quick, and very often it beats 



236 PERITONITIS. 

at the natural standard ; but towards the fatal termination it becomes 
rapid, weak, and intermitting. Vomiting is only an occasional symp- 
tom in peritonitis. The bowels are in general easily moved, drastic 
medicines are therefore not necessary. Thirst is a very general 
symptom in the pure inflammatory disease, but when the system is 
much oppressed by congestion, it is not urgent. The tongue is at 
first moist, and loaded with a white fur, but soon becomes dry and 
brown in the centre, and frequently it is observed to be very red at 
the tip and edges. The breathing is soon affected, if the inflammation 
be extensive, from the pain which the motion of the diaphragm pro- 
duces upon the tender peritoneum, as well as from the disordered 
state of the circulation. In the latter stage, however, the breathing 
becomes laborious, not only from the extensive effusion in the belly, 
and the increased disorder in the circulation, but frequently also from 
the pleura partaking of the inflammation. The brain, in most cases 
of acute and deadly inflammations of other parts, can scarcely escape 
embarrassment in its functions; therefore, we have almost always 
headache, if minute inquiry be made, and frequently delirium. When 
the peritoneal coat of the stomach is inflamed, the symptoms appear 
to be much more violent than when the disease affects any other 
part ; the pain is more severe, the vomiting incessant and intractable; 
the features collapsed; the pulse small, and the powers of life sink 
rapidly— this description will be found to correspond to that of the 
gastritis of authors. 

Causes. — Cold and fatigue, which occasion partial determinations 
of blood, and an irregular state of bowels, sometimes produce this 
disease, as well as contusions and wounds; sometimes it follows sur- 
gical operations. 

Pathology.— Until lately this was not understood. Cullen was 
unacquainted with it, and so was Dr. Gregory, I believe, to the 
latest period of his life. Many people of the present day, cannot 
fancy how it comes to pass that there is so much effusion with so 
little vascularity, but there is now no doubt that the effusion is pro- 
duced by inflammation of the peritoneum itself. 

In addition to the observations already made on the effects of in- 
flammation on serous membranes, at page 2S, &c. of this work, and 
those which will also be found at page 120,1 may now remark, that 
the absence of vascularity is no proof of the non-existence of inflam- 
mation ; pathologists rather trust to the well-known results of that 
action, which have also been established by experiment. Peritonitis 
was produced in dogs, which were then killed, and the vascularity, 
if recent, disappeared in the act of dying.* 

Treatment. — Bleeding, both general and topical, is to be had re- 
course to; in very slight cases we may trust to local bleeding by 
leeches, but when the inflammation is severe, the lancet should be 
used to such an extent as the nature of the case demands, so as to 
make a decided impression upon the disease and upon the system. 
Some physicians are, I believe, still in the habit of ordering the pre- 
cise quantity of twelve or sixteen ounces of blood to be drawn in 

* Vide Archives Generates for December, 1823, and January, 1824. 



PUERPERAL PERITONITIS. 237 

all cases, whether the disease be slight or severe ; the patient robust 
or weakly; at the beginning of the disease, as well as at any time 
during its progress. In all cases, the operator should be left to his 
own judgment as to the quantity, because he alone can judge of the 
effects, unless the physician chooses to attend himself. More than 
two or three hours should not elapse between the bleeding and the 
next visit, when it may be determined whether the operation ought 
to be repeated, or leeches applied. Perhaps it may not be found 
necessary to have recourse to either the one or the other, but we are 
nevertheless still to be on the watch. Laxatives are to be frequently 
repeated, assisted by large, unstimulating tepid injections. There is 
no necessity in this disease for giving drastic purgatives, because the 
bowels are in general not difficult to move; and if they should be 
found obstinate, two grains of calomel, and six of rhubarb, repeated 
every three hours, will produce more satisfactory stools, with less 
danger of producing irritation, than five grains of calomel and a 
scruple of jalap. As soon as the bowels are opened, an opiate may 
be given if there be any restlessness. Fomentations with very hot 
cloths are often serviceable in mitigating the pain ; but it is not yet 
decided whether they are more or less beneficial than cold applica- 
tions. Blisters are not to be had recourse to till late in the disease; 
and when they are thought necessary in serious cases, the abdomen 
should be completely covered. 

Many practitioners have great faith in digitalis in such cases, as a 
contra-stimulant, in doses of ten, fifteen, or twenty drops of the tinc- 
ture, repeated four or six times in the twenty-four hours; but al- 
though I have seen it tried in many cases of peritonitis, it has never 
operated beneficially, and, in such an acute disease, no confidence 
can be placed in any remedy which requires that we should wait 
twenty or thirty hours for its effects in controlling the circulation. 
If a remedy of this class be wanted, we possess a far better one in 
antimony • and better still, in acute affections of the bowels, is tobac- 
co, winch is to be administered by injection. 

If the patient be affected witb distension of the abdomen from 
tympanitis, ore have an admirable remedy in turpentine by injection, 
in the proportion of half an ounce, or an ounce, in eight or ten ounces 
of gruel ; or it may be put into the tobacco injection. The regimen 
is to be strictly antiphlogistic. 



ITKltl-mtAI. PERITONITIS Vll.CAItLY CALLED PUERPERAL FEVER. 

'I'm: nature of tins disease tl inflammation, and its seat the pcri- 
toi.«u in ; m thai ii ia exactly the same as the last afieotion Heated of, 
l)ui modified by the peculiar condition of the woman, and the nature 
of the prevailing epidemic. 

Symptoms. — There are two varieties of puerperal peritonitis, the 
purely inflammatory and tbe con^-suve; and I shall hereafter ex- 
plain i he reasons why the latter more frequently occurs m tbe puer- 
peral Itate than in the ordinary condition of the eystem. 

Ii is not necessary that I should enter into a detail of all the symp- 



238 PUERPERAL PERITONITIS. 

toms, because they are the same as those already described in com- 
mon peritonitis. It will be sufficient to notice some of the peculiar 
symptoms which Dr. James Hamilton, jun., and other symptomati- 
ca! physicians, call "pathognomonic " or, in other language, symp- 
toms which are present only when the disease is present, and absent 
•when the disease does not exist. These are pain in the belly, the 
state of the pulse, tympanitic distension of the abdomen, pain in the 
forehead, and the condition of the discharge, which takes place after 
delivery, called the lochial discharge. 

Mr. Burns, as well as Dr. James Hamilton, jun., has endeavoured 
to make it appear, that in peritonitis the pain is very severe; where- 
as, in what they choose to call puerperal fever, the pain in the belly 
is slight, or, to use the words of Mr. Burns, "abdominal pain is not 
the most prominent symptom." Dr. Hamilton is exceedingly ansry 
at a statement made by me in my work on "Puerperal Fever," 
that in his cases the pain in the belly was very acute, which he has 
been at much pains to deny, in a letter printed in a celebrated pam- 
phlet, which it has since been necessary to suppress ; but that the doc- 
tor lias been guilty of a subterfuge not very creditable to him, is easily 
proved, by looking back at his own account of the symptoms of the 
disease, in the old editions of his work. In the edition, 1813, page 
202, will be found the following passage : " In many cases the pain 
in the belly is such, that the weight of the bed-clothes proves intole- 
rable." But even allowing that the pain is often sub-acute, and not 
much complained of as a prominent symptom, if is no more than 
we frequently meet with in peritonitis in the ordinary state of the 
system. Dr. Abercrombie, in giving an account of the pain in com- 
mon peritonitis, says, "and in some cases, it is little complained of 
except when pressure is applied, being rather acute tenderness than 
actual pain."* 

Much stress is laid upon the pulse, by these gentlemen, in the 
form of the disease under consideration. They try to make it ap- 
pear, that in common peritonitis it is always "frequent, small, and 
sharp," whereas, in this disease, it is fuller, but soon becomes feeble. 
Another short quotation from Dr. Abercrombie's paper, will show 
the absurdity of this distinction. "The pulse (says he) is frequently 
little affected, especially in the early stages. It may be from 80 to 
90, or 96, but is sometimes scarcely above the natural standard." 

Early tumefaction of the abdomen is supposed to be peculiar to 
puerperal peritonitis; but as no professional man, who has been in 
the habit of treating inflammation in the abdomen, whose opinion is 
of any value, will again hazard such an assertion. I shall pass it over 
without further notice, as also the pain in the forehead. 

Lochial discharge. — All the -authors who have written upon this 
subject, including Mr. Burns himself, state that the lochial discharge 
is variable — that it sometimes flows as in ordinary cases, in some it 
is diminished, and in others suppressed. Dr. James Hamilton, jun., 
maintains that it never ceases in the true puerperal fever; and that 
it is "one striking mark of distinction between diseases which 

♦Edinburgh Medical and Surgical Journal, vol. xvi. 



PUERPERAL PERITONITIS. 239 

resemble each other in the. prominent characters offerer and pain 
in the belly.'''' Thus endeavouring to draw patliological distinctions 
from one symptom, confounding, as is his usual custom, cause and 
effect. 

Diarrhoea sometimes occurs in the course of this disease, and is 
always to be regarded with anxiety. If the secretion of milk have 
taken place, it almost always recedes, and the breasts become flaccid ; 
but the disease generally makes its attack before the secretion of 
milk commences, in which case it does not appear till two or three 
days after convalescence takes place. 

.Ippeurances on dissection — Dr. Abercrombie's account of the 
appearances found in peritonitis, occurring in the ordinary state of 
the system, is as follows : " On dissection we find uniformly effusion 
of coagulable lymph, in some cases very extensive; and frequently 
effusion of a turbid or punform fluid, sometimes in considerable 
quantity. Gangrene is rare, and, as far as my observation extends, 
never occurs as the prominent appearance, it being, when it does 
occur, slight and partial, and always accompanied by extensive 
deposition of coagulable lymph."* 

The following statement of the appearances found in the cases 
winch were treated by Dr. James Hamilton, jun., in the lying-in 
hospital, was published in the inaugural dissertation of his pupil Dr. 
Torrance, and acknowledged by Dr. Hamilton to be correct. 

i - We found (says Dr. Torrance) appearances similar to those ob- 
served by Hulme and Leake in the London hospitals. On examin- 
ing the abdomen, fetid gas sometimes issued from it. A fluid was 
always found in the cavity of the peritoneum. When the effusion 
w,ts in small quantity, it resembled milk, and joined the intes- 
tines together like glue; but when in large quantity, it had the ap- 
pearance of whey, and the adhesions were not so strong. We found 
small whitish portions of this matter in the folds of the intestines, 
which, when Btirred, gave an appearance of milk to the effused fluid. 
The peritoneal coal of the intestines had lost its usual pellucid ap- 
l" arance, felt hard, ami ramifications of red vessels were conspicuous. 
Tie, i- traces of inflammation, however, were not such as they should 
have be< n merely from an effusion of fluid into the abdomen. The 
peritoneal coal of the stomach seemed always sound. The muscular 
and cellular coats of the intestines were sometimes affected by an 
effusion between them. The villous coat was almost always natural. 
>Ul four or live pounds of a fluid, resembling coffee, were found in 
one or oiher of those affected. 

" The omentum, in some cases, firmly adhered to the intestines, and 
nbstance was so much affected, that it was torn in many places 
before it could be separated from them: bui il never seemed morti- 
. nor was it dissolved into a purulent ma iter, as Leake and I lulmo 
sav they have aeei] it. The internal surface of the uterus was sound, 
and never affected with inflammation. Suppuration of the ovaria 
was sometimes manifest In two or three cases, il seemed that the 
pleura had been involved in the inflammation, viz., by effusion, and 
other signs sufficiently mat 

• Bdilbafga lledieal and Surgical Journal, vol. xvi. 



240 PUERPERAL PERITONITIS. 

Pathological remarks. — 1st. The peritoneum is the tissue af- 
fected by inflammation in this disease, which extends itself through- 
out the whole extent of the membrane, without attacking one portion 
more than another, except that part of the peritoneum which forms 
the broad ligaments, in which situation, it is probable, the disease 
first commences. Nevertheless, the inflammation does not always 
appear to be general, the traces of its existence being sometimes 
confined to particular spots. 

2d. The effused fluid found in the abdomen of women who have 
died of peritonitis, has nothing peculiar in it; it resembles a similar 
effusion found in peritonitis in men, and in the thorax of those who 
die of pleuritis. It varies in consistence and colour in all these cases, 
but it is generally a white or reddish serous fluid, containing flakes 
of albumen, more or less abundant, according to the intensity of the 
disease ; and sometimes it has a puriform appearance. 

3d. The substance of the uterus has rarely been found diseased in 
this country at least, in any other degree than being sometimes large, 
flabby, and tender. But we have accounts of fatal epidemics on the 
continent, more particularly of one which occurred in Paris in 1829, 
in which not only the uterus, but the venous and lymphatic systems, 
suffered much.* 

4th. If a patient die in the early stage of peritonitis, we may find 
little vascularity, particularly if much blood have been drawn, al- 
though we are certain, from the previous symptoms, that inflam- 
mation had existed. If the patient survive longer, however, then 
we shall see the sero-purulent effusion. If the patient* live still 
longer, the quantity of effusion is increased, and masses of coagulable 
lymph will be found gluing the intestines very slightly together. If 
the patient live still longer, the intestines will be matted together, 
and false membrane will sometimes be found covering the liver, 
spleen, and uterus, and the peritoneum itself will then be seen very 
vascular, and much thickened. 

5lh. The pleura is frequently found inflamed in this disease, as 
indicated by a similar sero-purulent effusion ; and there is sometimes 
evidence of inflammation in the brain. 

6th. This disease is more rapid in its course, and fatal in its ter- 
mination, than ordinary peritonitis, from the peculiar condition in 
which a woman is left after parturition. In the first place, there 
has been an increasing determination of blood towards the uterine 
region during the previous nine months ; and in the second place, an 
increase of nervous irritability. So that the balance of the circulation 
is left at this period in a very disordered condition, being readily 
upset upon the application of any of the usual causes ; and when 
upset, the blood naturally takes its course towards the abdomen. 

These are at least some of the reasons for the venous congestion 
which takes place in many cases, in a greater or less degree, par- 
ticularly in women who have been worn out by breeding, or who 
have been debilitated by previous disease, or insufficient food and 

* Vide Archives Generates for March and April, 1830. The author has been 
induced to give a sketch of these forms of (what may be called) puerperal fever, at 
page 324. 



PUERPERAL PERITONITIS. £41 

clothing. Ill these cases, the heart and other vital organs are so 
much oppressed, that they cannot create reaction, or the system is 
too weak to do so. In one set of cases, speedy death takes place, the 
patient sinking without any marks of local disease, unless it can be 
said to be indicated by vomiting and diarrhoea, with some confusion 
of intellect. In another set, although considerable congestion has 
taken place, it is not to such an extent as to destroy the patient; 
inflammation attacks the peritoneum under a suppressed reaction, 
and it goes on with a surface which is almost bloodless: therefore 
there is little or no heat of skin; the pulse is small and weak ; the 
expression of the countenance ghastly ; and the pain in the abdomen 
perhaps sub-acute. There are various shades and degrees of this 
complaint, according to the various combinations of these two con- 
ditions of the system. 

There are three other causes which enable us to account for the 
rapid inarch and fatal termination of puerperal peritonitis. The first 
which I shall mention is the occurrence of inflammation of that part 
of the peritoneum which covers the stomach, giving rise to those 
most violent symptoms which are described by authors under the 
title of gastritis. In a majority of the fatal cases which have fallen 
under my notice, the peritoneum covering the stomach was highly 
inflamed; in several cases the whole stomach was in a softened state; 
and in all these cases there were most violent gastric symptoms. In the 
second place, inflammation of the peritoneum frequently takes place 
before delivery ; sometimes as the original disease, and occasionally 
from the extension of inflammation and ulceration from the mucous 
membrane of the intestines. The natural pains conceal the disease 
dining parturition ; afterwards the pain from inflammation is mis- 
taken for after-pains ; and, before alarm is taken, the patient is 
rally lost. Many examples of this have fallen under my notice 
since the publication of rny Treatise on Puerperal Fever, and I 
think I am now able to anticipate what is likely to follow delivery. 
1 hare lost only one patient out of between sixty and seventy who 
had the disease. In the third place, something may be fairly at- 
tributed to the nature of the prevailing epidemic. 

'i'mitmcnt <>j' puerperal peritonii is. — The only difference which 
exists between the treatment of peritonitis, in the ordinary condition 
of thfl system, and that which is now under consideration, proceeds 
from the two following circumstances: — We have a more severe 
and extensive inflammation to subdue, which is more frequently 
combined with venous congestion, which suppresses the inflamma- 
tion, and deceives the practitioner. If peritonitis attack a woman 
during the first two or three days after delivery, and is neglected for 
twelve hours, nay, in many instances, for six, any means we can 
employ, will, in all probability, be unavailing. It is for this reason 
that I Would rather treat the disease in a hospital than in any other 
situation; A physician, in Mich circumstances, requires almost to 

live with Ins patient, at least he should not be away from her bed* 
foi more than two hours at a tune ; nor will this lie a great hard- 
ship, should he even have live or six such patients on his hands at a 
tune— the battle is to be won or lost in the course of twenty-four 
I] 



242 PUERPERAL PERITONITIS. 

hours: but should it be sixty, a medical man must be always pre- 
pared to sacrifice his interest, and to disregard bodily fatigue, when 
the life of a fellow-creature is at stake. If he will rest upon a bed 
of roses, scarcely a patient affected with this disease will be saved; 
and if Dr. Hamilton visited his poor patients in the lying-in hospital 
only twice a-day, it so far enables the profession to account for Dr. 
Torrance's conclusion with regard to the practice pursued. " Copious 
bleeding, therefore, however much praised by Gordon, Armstrong, 
and Hey, in private practice, has always, on this recent occasion, 
deceived the hopes of the physicians of the lying-in hospital of Edin- 
burgh, and has been from necessity laid aside." Dr. Torrance says 
enough in one paragraph to show the profession the puny manner in 
which the bleedings were executed — that they were adopted "ivif fl- 
out any alleviation of the symptoms;" and the reader will be 
astonished when he is told the reason why Dr. Hamilton appears to 
have under-bled, particularly after perusing the above sketch of the 
appearances found on dissection. He conceives that the effusion of 
coagulable lymph, and the consequent gluing together of the bow- 
els, are produced by the bleeding ; but he shall speak for himself. 
"It appeared to me, (says he,) that the effusion into the abdomen 
was accelerated by the bleeding." 

Upon further experience I can speak with much confidence of the 
advantage of applying leeches. Many cases could be quoted, where 
one hundred, one hundred and fifty, two hundred, and two in which 
two hundred and forty were applied, first and last. They were very 
unpromising cases, but the ladies are now in the enjoyment of per- 
fect health and strength. Leeches are to be applied in numbers ac- 
cording to the age and constitution of the patient, and the period of 
the disease ;-but it must be mentioned, that some constitutions cannot 
bear their application. Whenever we are in doubt, therefore, it is 
better to apply fewer than we would otherwise do, and repeat them 
according to circumstances. An ordinary constitution can well bear 
the bleeding from two dozen, and plethoric individuals from 50 to 
100 at one application. When it is time to check the oozing of blood, 
we should see it done.. In one case, a delicate lady who was labour- 
ing under peritonitis, twenty leeches were applied to the abdomen. 
Her husband was a medical man, and lie ordered the nurse to stop 
the bleeding; she told him it had already stopped, and he went out 
on necessary business. On his return he found his wife in the ut- 
most state of exhaustion; upon examining her abdomen he found 
only one orifice bleeding, but the blood was coming per saltum. 
One of the leeches had penetrated a small branch of an artery. 
Stimulants were necessary, and she recovered from the state of syn- 
cope. This case is mentioned here as a warning to young practi- 
tioners. 

In the congestive cases, bleeding is to be had recourse to if called 
early, and iflhe pulse still possesses sufficient strength. Stimulants 
may be necessary at the same time, and I have already shown that 
stimulating and bleeding in such cases are not inconsistent with good 
pathology. The warm bath, stimulating frictions and also large 
blisters, are to be applied; and subsequently calomel and opium 



PUERPERAL PERITONITIS. 343 

may be used, together with the application of leeches. Consider- 
able suffering, and many relapses, depend on a tympanitic state of 
the bowels. By percussion this state is discovered, and the best 
remedy is an enema, composed either of oil of turpentine or assa- 
foetida. 

It is scarcely possible to give sufficiently precise directions regard- 
ing the circumstances which indicate the necessity for stimulants. 
Suffice it to say, that an experienced person derives the necessary 
information from the heat of the surface, condition of the pulse, and 
the expression of the countenance. If the surface be cold, or even 
cool, particularly if there be a cold clammy sweat; if the pulse be 
weak, irritable, or irregular and weak, and if the expression of the 
countenance be ghastly, no one could entertain a doubt as to the 
propriety of exhibiting stimuli at the termination of any inflamma- 
tory disease. 

Before concluding this subject, the proportion of deaths may be 
stated under each system, to enable the reader to draw his own con- 
clusions. 

The celebrated Dr. William Hunter saved one patient only out of 
thirty-two; his practice became fixed, to give a good wineglassful 
of brandy at the commencement of the disease. 

Dr. Huhne, who considered the disease partly of a putrid nature, 
and who employed bleeding in small quantities, and only as a se- 
condary remedy, lost almost every patient. 

Dr. Leake, who recommended bleeding in small quantities, and at 
long intervals, and who gave his patients bark, beef tea and cordials, 
to prevent putridity, lost thirteen out of nineteen patients in one 
season. 

Dr. Gordon, when he adopted a weak, vacillating practice, lost 
twenty-three out of twenty-seven cases; but afterwards he used early 
and large bleedings, and out of fifly lie lost only five. 

Mr. Hey, of Leeds, saved only three out of thirteen cases, before 

_■ in 10 bleed; but afterwards he was led, by sad experience, to 

I boldly and early, and he lost only two out of thirty-six patients. 

Dr. Armstrong, who seems to have profited early in life by the 
nance of Others, assures us he lost only five out of forty-three. 

On perusing tins statement, the reader will perceive the dilemma 

in wlneii Dr. .Limes Hamilton, Jim., is placed, and Will perhaps say 
in his own mind, that there is no hole through which he can escape; 
but alts! he dors not know the ingenious doclor; he will always 
•acape, but always in a manner peculiar to himself. The reader will 
say, he cannot now assert that the cases of these authors could not be 
ol puerperal fever because they had the lochia suppressed. It 
is, mderd, to be hoped he is not now guilty of such a blunder. What 
will the reader say, then, if Dr. James Hamilton, jun., were to try to 
>>■• from ihe dilemma, by such an extravagant statement as the 
following ? Suppose he were to say, he held his fatal casts, in which 
Heeding failed in curing the dise as e, to be more certain proofs of 
ihe iii'j/irnri/ of bleeding, than the production of forty-Jive cases 
where the patients recovered when bleeding hod been used; for the 
cases might not be of puerperal fever at all, as had really happened 



244 PUERPERAL PERITONITIS. 

in those cases cited by Drs. Gordon and Armstrong, and Mr. Hey, 
of Leeds, where theirs terminated favourably under the lancet ; or 
if they were really cases of the disease, he maintains that not the 
bleeding, but a natural change in the constitution, going on before 
that remedy had been employed, had effected the cure. 

His fatal cases afford positive proof; the forty-five 
favourable cases afford only negative. The reader may here 
say, it is impossible that even a professor of the University of Edin- 
burgh, low as she has fallen in some of her medical chairs, could 
make such a statement. My answer to this is, that I shall be glad. 
to be afforded an opportunity, upon Dr. Hamilton's authority, of de- 
nying that he could ever have committed such an outrage upon com- 
mon sense. This statement and offer were made in my first edition, 
entitled « Heads of Lectures," in 1S28, and repeated in each subse- 
quent edition. 

In Dr. Abercrombie's work on the Bowels, p. 1S9, the following 
passage will be found: — "I have little doubt that women in the 
puerperal state are liable to tiuo distinct forms of peritonitis, which, 
in the discussions on this subject, have probably not been sufficiently 
distinguished from each otherP Then the only conclusion which 
can be drawn is, that the author never perused the works to which 
he makes such a faint allusion. The. two distinct forms, answering 
precisely to the description by Dr. Abercrombie, were most emphati- 
cally pointed out by the late Dr. Armstrong, and more recently by 
myself. I could give a true explanation of Dr. Abercrombie's specu- 
lation were it necessary; in the mean time I shall leave him to enjoy 
the reward due to his discovery !* 

Another and fatal variety of disease sometimes takes place 
after delivery, which must be noticed in this section, although it 
is not always connected with peritonitis. The fatal variety consists 
of hysteritis, or inflammation of the uterus, uterine phlebitis and in- 
flammation of the absorbent vessels of the uterus. Following the 
order which Dr. Lee has adopted, I shall treat, 1st, Of inflammation 
of the substance of the uterus. 2d. Inflammation of the absorbent 
vessels of the uterus. 3d. Inflammation of the veins of the uterus. 

1st. Inflammation of the uterus. — Symptoms, hypogastric pain; 
diminution or suppression of the lochia; rigors; rapid, feeble pulse; 
countenance pallid, expressing anxiety and distress ; cerebral disturb- 
ance, viz., headache and delirium; skin hot and dry, frequently 
sallow; respiration hurried; great prostration of strength; tongue 
loaded and foul ; dark sordes about the mouth. Nausea and vomit- 
ing are occasionally experienced. The course of the disease is some- 
times fearfully rapid, at others it is not fatal till towards the end of 
the second week. It is stated that the diagnosis "is extremely diffi- 
cult." I have frequently seen cases of peritonitis, in the puerperal 
state, with equally distressing symptoms and speedy death, in which 

* I do not think it necessary to notice formally, the analogy which Dr. Abercrombie 
has endeavoured to form between puerperal fever, when it is severe and fatal, with 
erysipelas, because he does not bring a shadow of proof in its support. It is most 
improbable that serous membranes are liable to erysipelas; so say Bayle, Gasc, and 
all the most esteemed pathological inquirers of the present day. 



PUERPERAL PERITONITIS. 245 

the most careful examination after death proved every part of the 
uterus to be sound, but its peritoneal coat. 

At page 276, of a former edition, the severe epidemics that had 
occurred on the continent, more particularly that at Paris, in 1S29, 
were briefly noticed. During the epidemic at Paris, there were 
forty-nine out of two hundred and twenty-two fatal cases, in which 
the uterus was more or less disorganized. 

As to the treatment, Dr. Lee states, that "in all the cases of this 
affection, which we have observed, the resources of nature and of art 
have proved equally unavailing in averting its fatal course."* 



Extract from the Report of the Dissections ofivomen who died in 
child-bed in the General Hospital of Vienna, from 26th July to 
the end of Jlugust, IS 19, by Dr. Biermayer. Extracted from 
the Edi>tburgh Medical and Surgical Journal for July, 1824. 
Vide No. 80, page S3. 

Fifty-six bodies were examined. — (i In the head, the organs were 
all turgid with blood; the ventricles generally contained more than 
the usual quantity of serum; in other respects there was nothing 
worthy of notice in reference to this disease. 

" In the trachea there was generally found a sanguineous fluid, 
and its internal surface was reddened. 

"The lungs were always in the greatest state of expansion, turgid 
with blood, frequently adhering or united by effused lymph to the 
pleura, which was generally, but not in all cases, slightly red. 

"In the cavity of the thorax and pericardium, there was invari- 
ably more than the usual quantity of bloody serum; the pericardium 
in no case morbidly changed, nor the heart externally; but its sub- 
stance, without exception, more flaccid and tender than in the healthy 
st in-, [m internal surface, particularly the valves, chiefly of the 
right sid'-, <>(' a deep red, often of a black colour; the mass of blood 
illy fluid. 

a In the abdomen there were only two cases in which there was 
no unnatural fluid, i. e. t in those cases which had been delivered a 
eoneiderabte lime before death. In all the rest, there was found 
from on.- to tuo quarts of turbid, very fetid fluid, mixed with por- 
tions of coagulated lymph, and sometimes purulent matter; the latter 
appearance was observed in those cases where powerful I antiphlo- 
gistic means had been employed, and who had survived longer after 
delivery. 

••The peritoneum, omentum, and mesentery, exhibited, in five 
only, no appearance of redness; in the rest it was always some- 

• I have met with one ease only of iiiis disease, and therefore feel thai I an Del 

qualified, either t" jive an opinion, it to wtite on the subject. I shall therefore take 

f of giving a brief abstract fromDr Robert Lees paper on puerperal fever, 

ianafhh parts of the Cyclopaedia of Practical Medicine. The profession 

li inn.'. Indebted t" this lealoos and talented pathologist, for his investigatioBe pa 

for in, following out the unparianl discovery of the pathology 

of phlegmasia dotens by Profe oi Davl , 

1S» 



246 PUERPERAL PERITONITIS. 

what more or less red, particularly towards the pelvis; and they 
were often agglutinated with the adjacent parts. 

"With the exception of two cases, the stomach and intestines were 
always much distended with air, and their external surface more or 
less red. Lumbrici frequently appeared in great numbers, not only 
in the small but also in the large intestines, in the stomach, rectum, 
and in one case, in the nostrils. 

"The liver and spleen were always similarly affected; they were 
much more pale, flabby, and tender, than in their healthy state; 
easily broken down with the finger, similar to the degeneration of 
the uterus, and filled with somewhat fluid blood ; **-**.* * 
the gall bladder was always filled with dark bile. The pancreas 
always healthy. 

" The kidneys, in most of the cases, were flabby and tender. The 
uterus always somewhat enlarged and red. The urinary bladder 
always contracted. 

" The internal organs of generation were everywhere covered 
with yellow coagulated lymph, except in two cases, in which no 
fluid was found in the abdomen; and in those cases in which strong 
antiphlogistic means were used, there was frequently a thick, yellow, 
purulent fluid, often externally on the neck of the womb. The 
ovaria and fallopian tubes were always more or less swollen, red 
and tender. 

"The uterus, in all cases little contracted, was more or less red 
externally, even in those where delivery had taken place long be- 
fore, and the abdomen was not otherwise in an unhealthy condition. 
The substance or body of the uterus was always flabby, tender, 
easily broken down by the finger; in two cases, full of small holes 
or cavities filled with stinking blood. In two cases, the uterus, on 
account of the tenderness of its substance, had burst, during delivery, 
at its neck: in the one case, the rupture was four inches in length, 
and in the other, one inch and a-half. The cavity of the uterus was 
found filled with fetid air several times, particularly in two syphilitic 
women. Its internal surface appeared generally covered with offen- 
sive, cineritious ichor, or mucus only, seldom with offensive viscid 
blood. Beneath this, it was always red, discoloured, often, as if 
slightly eroded or ulcerated; the internal membrane very much 
eroded and destroyed." * * * * * 

Such are the principal facts, carefully abstracted from the whole 
56 dissections. 

We are further told, in this report, that the symptoms were such 
that the "inflammation of the uterus and peritoneum, combined 
ivith high fever, could not be mistaken.' 7 The lochia disappeared 
either immediately, or in a few hours; and the mammae were found 
empty of milk, loose, and flabby. " But, (says the report,) the most 
alarming circumstance was, that, while the disease was yet in all 
appearances a recent acute inflammation, Dr. Boer, on examination 
with the finger, already discovered, in the mouth of the uterus, marks 
of gangrenous disorganization, which were rendered evident even to 
the by-standers, and by the putrid smell of the finger." 

2d. Inflammation of the uterine absorbents. — Dr. Lee has given 



PUERPERAL PERITONITIS. 347 

the particulars of four fatal cases of inflamed uterine absorbents, in 
his paper on Uterine Inflammation in Puerperal Women, in 15th 
vol. Med. Chir. Trans, of London; and he has quoted a case, which 
appears to have been the first, in which the absorbents of the uterus 
were filled with pus. 

With respect to the symptoms there is much obscurity. "The 
local symptoms (says Dr. Lee,) of this affection are often so obscure 
as to escape detection during life ; while the constitutional symptoms, 
which often resemble in a striking manner the effect produced by 
the introduction of specific poison into the body, are so violent as to 
yield to no remedies, however early and vigorously employed." 

3d. Inflammation of the veins of the uterus. — It would appear 
that a large proportion of these cases termed "low child-bed fever," 
or typhoid " puerperal fever," are connected with this morbid lesion. 
Dr. Lee states, that since the year 1S27, twenty-four examples of 
this most insidious and fatal disease have fallen under his observa- 
tion. He has given the following description of the phenomena. 
" In women, who have enjoyed good health during pregnancy, and 
in whom the process of parturition has been easily accomplished, 
uterine phlebitis occasionally commences within twenty-four hours 
after delivery, with pain, more or less acute, in the region of the 
uterus, accompanied or followed by a severe rigor, or a succession 
of rigors, a suppression of the lochial discharge, acceleration of the 
pulse, cephalalgia, or a slight incoherence of intellect, with most dis- 
tressing sensation of general uneasiness, and sometimes by nausea 
and vomiting. These symptoms, after a short duration, are suc- 
ceeded by increased heat of the body, tremors of the muscles of the 
face and extremities, rapid, feeble pulse, anxious and hurried respi- 
ration, great thirst, with brown dry tongue, and frequent vomiting 
of green-coloured matters. The sensorial functions usually become 
most atfected, and there is a state of drowsy stupor, or violent deli- 
rium and agitation, which is followed by symptoms of extreme ex- 
haustion; the whole surface of the body not unfrcquently assumes 
n deep and peculiar sallow, or yellow colour; the abdomen some- 
times becomes swollen and tympanitic; and some of the remote 
IU of the body, BUch as the lungs, heart, brain, liver, and spleen, 
or the articulations Bnd cellular membranes of the extremities, sutler 
disorganization from congestion, or a rapid and destructive inflam- 
mation." Dr. Lee adds, "there is scarcely an organ of the body, 
wbieb has nol been observed to become secondarily affected, from 
suppuration of the uterine veins." Occasionally, uterine phlebitis 
"commences at B later period alter delivery than above described, 
and in a much inure obscure and insidious form, without pain or 
of uneasiness in the region of the uterus, or any other local 
lymptora by which the affection can be recognized. The uterus 
may return to the reduced volume it usually assumes after delivery; 
the lochial discharge may continue, and the inflammation and sup- 
puration of the veins, which have caused the whole of the violent 
constitutional disturbance and destructive lesions in distant parts of 

the body, may have I-"-'!! wholly overlooked during life. In many 
I which ore have witnessed this error was committed bv the 



£48 PUERPERAL PERITONITIS. 

medical attendant, and stimulants were liberally administered, to 
obviate the debility supposed to exist in a specifie form, without 
any local affections of the uterine organs." The effects of inflam- 
mation in the uterine veins are, "the formation of adventitious 
membrane on their inner surface, and the deposition of coagulable 
lymph, or of purulent matter within their cavities." " The inflam- 
mation may be limited to the veins, but not unfrequently the mus- 
cular tissue, contiguous to them, participates in the inflammation, 
and becomes of a dark red or blackish colour, and of an unusually 
soft consistence. The peritoneal covering may also be affected, and 
the usual consequences of puerperal peritonitis then ensue." 

The subject is one of immense importance, and I trust, therefore, 
to be excused for quoting the following additional interesting pas- 
sages, respecting the peculiar state of the veins. " The veins (says Dr. 
Lee) which return the blood from the uterus and its appendages, 
may be either wholly or in part inflamed ; generally, however, (and 
this is a circumstance in the history of uterine phlebitis, deserving 
particular attention,) the inflammation attacks the spermatic veins 
alone, and, for the most part, the one only on that side of the uterus 
to which the placenta has been attached ; and it may either confine 
itself to a sfnall portion of the vessel, or extend throughout its whole 
course, from the uterus to the vena cava." " The same is the case 
with regard to the hypogastric veins, one only being generally 
affected. These are, however, more rarely affected than the sper- 
matic veins; and this would seem to depend on the latter veins being 
invariably employed to return the blood from that part of the uterus 
to which the placenta had been attached. 

"But the inflammation having once begun, it is liable to spread 
continuously to the veins of the whole uterine system, to those of the 
ovaria, of the fallopian tubes, and broad ligaments. The vena cava 
itself does not always escape the inflammation spreading to it from 
the iliac, or from the spermatic veins. This seldom takes place to a 
great extent, through the medium of the spermatic, the inflammation 
usually terminating abruptly at the opening of the spermatic into the 
cava on the right side, or of the renal on the left, &c. &c. 

" When the inflammation affects the hypograstric veins, it may 
extend from these to the iliac and femoral veins, and thus give rise 
to all the phenomena of phlegmasia dolens." 

Causes of uterine inflammation. — All the forms now noticed may 
be owing to mechanical injury from some pressure which the uterus 
sustains in a protracted labour, in which the child is very large, or 
the pelvis rather small. They may also be produced by rashness in 
extracting the placenta, when the hand is introduced for that pur- 
pose into the cavity of the uterus, more particularly, perhaps, in cases 
of indurating of the placenta. It is said that uterine phlebitis may 
follow the retention of portions of the placenta undergoing decompo- 
sition in the uterus. Dr. Lee allows, that although a dangerous dis- 
ease, uterine phlebitis is not invariably fatal; and that "it often 
occurs in puerperal women, where it is not suspected," he thinks, is 
demonstrated by the fact that, in the spermatic and hypogastric veins 
of females advanced in life, calcareous concretions, and various kinds 



CHRONIC PERITONITIS. 249 

of disorganization, have frequently been observed, which must have 
been the consequence of attacks of acute inflammation at some re- 
mote period. 

I may remark, in reference to the last paragraph, that the term 
" phleboiites," has been applied to those bodies found in the sper- 
matic and hypogastric veins; and that the attention of the profession 
has been called to this subject by Beclard, in his Anatomie Generale, 
and by Cloquet, in his Pathologie Chirurgicale. It has been ably 
followed up by Dr. John Reid, an accomplished anatomist of this city, 
the result of whose labours on this subject will appear in the Edin- 
burgh Medical and Surgical Journal, before this edition can possibly 
be published. 

With regard to the treatment of these three severe varieties of 
uterine inflammation, I cannot speak from my own knowledge, and 
therefore am induced to borrow still further from Dr. Lee. He states, 
i hat u in cases where the reaction at the invasion of the disease has 
been violent, and venesection has been employed, the relief obtained. 
lias only been temporary, if at all experienced; and in some instances 
the abstraction of only a few ounces of blood from the arm, has pro- 
duced alarming syncope. When the local pain is severe, leeches and 
warm fomentations seem to be the appropriate remedies; but, as far 
as our observations go, we are in possession of no remedial means 
Which effectually control these varieties of inflammation of the deeper 
seated structures of the uterus, which we have attempted to de- 
scribe." The French practitioners place great reliance on the action 
of mercury pushed quickly to salivation. Dr. Lee states, that he gave 
this practice a fair trial; and that it failed, although he pushed it to 
great extent, and brought the system under the influence of mercury 
in less than twenty-four hours; "Yet the progress of the symj>tom$ 
Was not arrested, and the patients died, as others had done where 
the remedy lt<i<t not been ail ministered.'''' 



CHRONIC PSBITOITITIS. 

This form of disease sometimes succeeds to acute action in the 
lometimes it is occasioned by the extension of ulceration 
from the mucous coal of the bowels; and occasionally it is itself the 
primary disease, in winch case the attack is often very insidious. 

Symptoms. — Pains are occasionally felt in various parts of the 
abdomen, With B sense of weight or oppression ; the pains come on 
in paroxysms, which are sometimes very severe, at other times a 
pricking sensation only is felt. In some cases pain is not a promi- 
nent symptom; the belly is tumid, with occasional tightness, while 
the r<st of the body emaciates, and the strength declines slowly; 
fever Is often present, thai is to say, the pulse is tjnick, ol variable 
strength end fulness, with thirst and restlessness. The tongue is in 
various states, either loaded 01 very red, or both; constipation is a 
usual attendant f<>r some tfme, bm subsequently diarrhoea generally 

takes pi tee ; the StOOla Often have a very natural appearance. The 



250 CHRONIC PERITONITIS. 

patient in all cases also experiences a sense of increased weight and 
uneasiness in the abdomen after a meal. 

Chronic peritonitis runs its course to a fatal termination in various 
periods; I have known it of eighteen months' standing, and some- 
times the patient is destroyed in a few weeks. In the last stage, the 
symptoms become aggravated ; the features shrink; emaciation takes 
place to the greatest possible extent, and sometimes death appears to 
be owing to ihe patient's being worn out ; or from an attack of con- 
stipation having all the symptoms of ileus, or from the supervention 
of acute inflammation, perhaps in the cavity of the thorax; all of 
which terminations I have seen. 

It is in general a fatal disease, but I have seen some wonderful 
recoveries, if one may be allowed to judge from the appearances of 
thickening of the peritoneum, and extensive adhesions in the bodies 
of individuals who had survived the attack for a number of years, 
enjoying a tolerable share of health, and dying at last from the effects 
of other diseases. I lately attended a child who was observed to fall 
off in health and strength, and to complain occasionally of abdominal 
pain; he was feverish at night, but during the day was able to play 
about with the other children of the family; his body emaciated, 
while the abdomen became larger. Suddenly a decided change for 
the worse took place. The abdomen became more distended and 
painful, the fever increased, and he was confined to bed. In a few 
days a fulness was observed in the umbilical region, and an inflam- 
matory blush. A natural opening soon took place, and a bilious- 
looking matter was discharged, with portions of food, such as barley, 
&c. When the discharge ceased, the symptoms became aggravated. 
He lived for some months. On examining the abdomen alter death, 
there was an appearance of an abscess extending for several inches 
around the umbilicus, and immediately in contact with the intestines, 
round the circumference of which there were strong adhesions. In 
this cavity there was matter similar to that discharged through the 
external opening. On looking attentively at the parts, there were 
found nine openings into different parts of the intestinal tube. Some 
of these were large, others small ; the orifices were ragged, and 
appeared to be the effect of ulceration, which opinion was amply 
confirmed by a minute examination of various portions of the 
mucous membrane, in whicli ulcerations in various stages were 
observed. The contents of the abdomen were all matted together, 
and the mesenteric glands were enlarged, and the mesentery thick- 
ened. 

Chronic peritonitis is sometimes mistaken for other diseases, chiefly 
for dropsy, dyspepsia, and hepatitis. 

Causes. — It has been already stated, that this disease sometimes 
follows an acute attack, and as the consequence of it. It is also 
produced by the extension of ulceration from the mucous coat of the 
bowels; hence it sometimes occurs as one of the sequelae of fever, 
diarrhoea, and dysentery. It is occasionally caused by external 
violence. It may be also produced among the children of the poor 
by insufficient clothing, the use of unwholesome food, as well as by 
the continual irritation from worms. In women it sometimes occurs 



CHRONIC PERITONITIS. 251 

at that period of life when the menstrual discharge ceases. It is 
prohable that chronic peritonitis is often the consequence of irrita- 
tion, produced by dysmenorrhea, tumours growing from different 
parts of the uterine system, and by extra-uterine pregnancies. 

Appearances on dissection. — The whole intestines are sometimes 
agglutinated into one solid mass, involving the liver, spleen, and 
other parts; generally, however, we find the intestines and omen- 
tum only in that condition. Occasionally it is seen to affect the liver 
and parts in its neighbourhood, which are covered with a false mem- 
brane that can be readily peeled off, leaving the peritoneal coat 
attached to the organ. The disease may he confined to the contents 
of the pelvis, as is sometimes seen in scirrhous affections of the rec- 
tum and uterus, and diseases of the ovaria. It appears to me, from 
the repeated examination of extensive adhesions of the pelvic con- 
tents, in connection with a small and circular os uteri, that chronic 
inflammation of the peritoneum may hereafter be found to be pro- 
duced by the constant suffering, and consequent state of irritation, 
during the course of dysmenorrhea. Occasionally the peritoneum 
is thickened everywhere without adhesions; but tins is more fre- 
quently observed when there is an effusion of a serous fluid into the 
cavity of the abdomen, and particularly if it exist in any quantity. 
Sometimes the effusion is puriform. The colour of the peritoneum 
vanes exceedingly ; it is sometimes almost as red as if painted with 
vermilion, with large red vessels ramifying indifferent directions; 
sometimes the redness is confined to particular spots, as if produced 
by ecchymosis; in other places it is yellow, blue, purple, slate-coloured 
black; but perhaps some of the discoloration may be owing to post- 
mortem changes. In some rare instances, the peritoneum appears 
smooth; in general it is rough from irregular elevations; ragged, 
winch last appearance is sometimes, though rarely, produced by 
ulceration ; most frequently it is occasioned by the rough state of the 
membrane itself, and by very fine long irregular bands forming ad- 
ins. On some occasions, the peritoneum presents partial fungosi- 
slightly elevated, extending in patches of irregular shapes, and 
of a red colour, looking very much like a coagulated bloody effusion. 
Chronic inflammatory action in the peritoneal coat, is a frequent 
C8JUM Of tubercular formation. I have seen tubercles in the perito- 
nei mi lining the general cavity, covering the intestines, stomach, liver, 
and spleen; also in the peritoneum which forms the omentum, me- 
sentery, and mesocolon. Sometimes the mesenteric glands are also 
Affected, bill I have never seen them so without finding the corre- 
al' Iiiil' parts of the mucous membrane of the intestine inflamed, 

more generally extensively ulcerated; so that [appreheud the too 

■Weeping term scrofula, has hern applied to these foimations upon 

limited or erroneous pathological views. The tuberculated state of 

the peritoneum generally takes place after the lungs have been at- 

■ I wiih the same disease; sometimes from chrome inflammation 

of the peritoneum, particularly when u succeeds to external violence. 
The tubercles on |ha peritoneum are sometimes of the miliary kind, 

ittonally crude, sometimes hard, and of various sizes up to that 
of an oran uially resembling masses of coagulated blood; 



252 CHRONIC PERITONITIS. 

at other times having very much the character of the diseased struc- 
ture termed medullary sarcoma, and they exist either singly, or in 
groups, hanging like bunches of fruit. 

The description is drawn from cases and dissections which have 
fallen under my own observation ; and my museum and portfolio 
contain preparations and representations of all the morbid appear- 
ances above stated, which were capable of being so preserved. 

Treatment. — This disease is frequently a hopeless one, before 
medical advice is sought ; but if the case should be ever so hopeless, 
it is the duty of a physician to use his best exertions up to the very 
period of death, as remarkable recoveries have been known to take 
place ; indeed, I have remarked, that in proportion as pathology has 
advanced, the old practice of "giving up" patients has declined. We 
can almost always mitigate the violence of the symptoms, and place 
the patient in a comparatively comfortable situation, when there can 
be no hope either of curing the disease, or of prolonging life. The 
question of general bleeding can rarely be entertained; yet I have 
met with a few cases in which it was loudly called for, and was pro- 
ductive of benefit. The frequent application of leeches, whenever 
a patient complains of pain, is of great service, together with contra- 
irritation produced either by stimulating embrocations, tartar emetic 
ointment, or common blisters. Hot applications to the abdomen 
may be useful, together with the frequent employment of the warm 
bath. Assiduous attention to the bowels, however, forms a most 
essential part of the treatment ; this is to be done, not by strong pur- 
gatives, but by very gentle laxatives united with hyoscyamus, and 
large tepid unstimulating injections used regularly once, sometimes 
twice a-day. Opiates are sometimes serviceable, but their use is 
often contradicted by constipation. The employment of drastic pur- 
gatives in these cases cannot be defended, and three cases might be 
stated within my own experience, in which they produced fatal 
attacks of acute peritonitis. It is almost unnecessary to add the im- 
portance of attention to diet, which should be nourishing, but bland 
and unstimulating, as well as easy of digestion. Ass's milk once or 
twice a-day, is therefore to be employed ; but patients should avoid 
distending the stomach much, and taking any article which they 
know from experience will produce flatulency, as the violent parox- 
ysms of pain, which have been mentioned in the description of the 
symptoms, may frequently be traced to the presence of flatus. The 
knowledge of this will therefore lead us, during such a paroxysm, to 
give a carminative; but a turpentine injection will answer better. 
Exercise should be avoided, if motion produces even the slightest un- 
easiness. 



INFLAMMATION OF THE MUCOUS MEMBRANE, &c. £53 



INFLAMMATION OF THE MUCOUS MEMBRANE OF 
THE STOMACH AND BOWELS. 

Before treating of the different diseases depending upon morbid 
states of the mucous membrane of the stomach and bowels, it will 
be of advantage to the student to give a sketch of the different 
changes produced by inflammation in that tissue. 

It is a point of the first importance to determine the natural con- 
dition of the mucous membrane, in order to enable us to ascertain 
the appearances produced by the disease. It is admitted, I believe, 
by every one, that the mucous membrane of the stomach ajid bowels 
presents, in the most healthy state in which we see it after death, a 
whitish appearance, with a slight tint of rose colour; that although 
blood-vessels may be seen here and there, yet they are not observed 
arborescing in great numbers, nor do we see any discoloured patches, 
unless there has been some great impediment to the circulation, or a 
natural change towards decay. Indeed, it is to be apprehended that 
some of the tints, described with so much minuteness and accuracy by 
French pathologists, may be attributed to this last cause. It is stated 
that the stomach becomes more vascular, and of a redder colour, 
during the act of digestion, than at any other period; which appears 
to be very probable, and may account for the red appearance found 
in the bodies of criminals after execution. 

On opening the stomach of an individual who has suddenly died 
from accident, or from some disease unconnected with the bowels, 
the mucous membrane will be found slightly coated with mucus, 
which is not diiiicult to remove; and if the body have been opened 
within two or three days after death, it will be found in numerous 
folds or rugae, which seem to be produced by the contraction of the 
muscular coat of the organ, leaving the mucous membrane free, so 
that it forms itself into folds, which it is conceived have nothing to do 
with a diseased condition of the inner membrane itself In a healthy 
stale, the mucous membrane is not easily abraded. 

The pan of the stomach which appears to be most liable to in- 
flammation, is the splenic extremity. In considering the diseased 
appearances of the Btomach and intestines, it will be best to do so 

under the following lour heads; viz. colour, vascularity , v.cudittion, 
alteration* qf structure, 

l. With respecl to the colour, we have to determine whether or not 
it be owing i" post-mortem changes ; and we must also be careful to 
avoid ill" error into winch Broussais and bis disciples have some- 
times fallen, of attributing every change of colour to inflammatory 
action. The reader is referred to Dr. JTellowly's observations on the 
tppearances in the human stomach, which are frequently 
mistaken for inflammation in that organ,* and more particularly to 
tli«- first aid third cases, in which the whole intestinal canal was mi- 
nutely injected Willi dark-COlOlired Mood in individuals who sullercd 

the last sentence of the law. in these cases. Dr. Yellowly very pro- 

• Id th- 1ih vol. of the London Mcdico-Chirur^icul Transactions. 
22 



254 INFLAMMATION OF THE MUCOUS MEMBRANE 

perly supposes, that the circulation is carried on in the capillaries for 
some time after death. The appearance of (he vessels, the exuda- 
tion, and the structure of the mucous membrane itself, will, however, 
generally inform us, whether the colour described in Dr. Yellowly's 
paper is fortuitous, or owing to diseased action. 

We must also be careful to distinguish whether the colour depends 
on infiltration of blood into the sub-mucous tissue, or on inflamma- 
tion of the membrane itself. A section of the part will show this at 
once ; for on looking at the cut edges, we shall see the mucous mem- 
brane separated from the muscular coat by the infiltration; the former 
having its usual healthy appearance. But it must be recollected that 
inflammation and infiltration very frequently co-exist; and when we 
■wish to decide whether the mucous membrane is discoloured, the 
suspected part must be extended upon the finger, and a scratch made 
with a scalpel through the mucous coat itself, which will give us an 
opportunity of ascertaining its vascularity and structure. The chief 
discolorations of the mucous membrane resulting from disease, are 
bright red, dark red approaching to purple, brown, slate-coloured, 
and black. Minute shades of these colours are not noticed, because 
they are unimportant; nor shall I mention a number of other dis- 
colorations which are seen on dissection, because they are very 
doubtful signs of disease. It must be confessed, after all, that we are 
very liable to be deceived about the colour, as it is the most frequent, 
and, I apprehend, the first post-mortem change which takes place. 

2. Vascularity. — Our attention should, in the first place, be di- 
rected to ascertain whether the vascularity is arterial or venous; if 
the latter, large, dark-coloured veins will be observed ramifying 
under the mucous membrane, and there will be tew minute arbore- 
scent vessels containing red blood. In fact we shall see the appear- 
ances which Dr. Yellowly has so faithfully described in the two cases 
already quoted ; in the first of which, " the whole of the abdominal 
viscera were loaded, as if by minute injection, with dark-coloured 
blood. Here and there, however, there were florid vessels, which 
were distinctly traceable into dark-coloured ones. ,y In the other, 
"the whole of the intestinal canal was minutely injected with blood, 
which was, for the most part, of a dark crimson or purple, but here 
and there of a florid hue. ,, If the vascularity be arterial, and con- 
nected with inflammatory action, we shall see red points, or nume- 
rous red vessels, running in lines or patches, with or without ecchy- 
mosed spots in the mucous membrane. We shall observe them, not 
in depending parts only, in which situation they are always doubtful 
signs of inflammation, unless accompanied by a corresponding exu- 
dation or alteration of structure. It is always necessary to make a 
section, first of the mucous membrane, and then of the other struc- 
tures, to prove whether the vascularity exists in the mucous coat or 
in the other tissues, or in all of them; if in the former, a slight cut 
made through the mucous membrane will divide the vessels, a little 
blood will exude, and the parts beneath will have their natural white 
appearance; and, upon tearing away the mucous membrane with a 
pair of forceps, the white appearance of the subjacent parts will be 
still better seen. The vascularity is doubtful when there is disease 



OF THE STOMACH AND BOWELS. 255 

of the heart, or any other cause which obstructs the circulation. 
Even in that case, however, I imagine the vascularity must be re- 
garded as a diseased appearance; and particularly when it is recol- 
lected that it frequently terminates in inflammation, and even ulcera- 
tion, as will be shown hereafter, when treating of phthisis. 

In estimating the extent of the vascularity, we ought to recollect 
that it must diminish very considerably after death, and particularly 
in recent inflammations. The tunica conjunctiva of an ophthalmic 
patient, loses its tumescence and redness at death, or soon after. 

3. Exudation. — The first effect of inflammation on all secreting 
surfaces, is supposed to be a diminution of the natural secretion ; but 
it is not certain whether this holds good in the mucous membrane of 
the stomach and bowels. In several instances it has presented a dry 
appearance, but these were cases of long standing chronic inflamma- 
tion. The exudation merits our careful attention with regard to its 
tenacity, quantity, and colour. If it be viscid, and in considerable 
quantity, upon a surface which presents many red vessels, however 
partial the vascularity may be, it is to be regarded as the product of 
irritation or inflammation. It varies very much in colour, from that 
of ordinary mucus to pus; and a red matter like currant jelly is fre- 
quently found : the exudation has been represented to be occasion- 
ally so corrosive as to excoriate the fingers of the dissectors ; but it 
is probable there is some mistake about this statement. There can 
be no doubt, however, that the mucous membrane yields a large 
quantity of (hick tenacious mucus, colourless like starch, when it is 
under the influence of any kind of irritation ; this is well illustrated 
in the experiments performed with the tartrate of antimony in con- 
rable doses, which were published by me in the 25Sth number 
of the Lancet. With respect to the red exudation, two kinds are 
observed : one, like very red currant jelly, which is produced when 
tin- membrane is under a high degree of inflammation ; the other, of 
a much darker hue, darker even than venous blood, more fluid than 
the other, and occasionally discharged in very large quantity ; this 
will, in '_ r ''i)<T a 1 , be found m cases where there is great congestion of 
the mucous membrane, along with Borne degree of inflammation. 
\ disc large often takes place in diseases of the liver and 

(The mucous secretion is sometimes replaced by a secretion of 
}>us, though tins condition is [infrequent. M. A.ndral observes that, 
on one occasion, he found the whole of the colon lined with a deep 
layer of thick pus, exactly resembling that of a phlegmonous abscess. 
It is, however, more commonly met with in the follicles, which form 
small tumours on the surface of the intestine.] 

i. Alteration* of structure. — The first appearance which falls 
noticed, is the pulpiness, with thickening of the mucous mem- 
brane. When u is in this state, the Btirface, if closely examined, 
rough and granular, and the membrane can be easily rubbed 
oil". Abrasions are sometimes seen, lan not so frequently the result 
cute inflammation as <,i chronic; at all events, [hey are not so 
i '■! appearance, however, concerning which wo 

are r< ry li ible to be deceived \ for when the membrane is soft, 
abrasions arc easily produced by handling. Those which are the 



256 INFLAMMATION OF THE MUCOUS MEMBRANE 

consequences of disease, will be readily recognised by placing the 
part in water, a portion will be entirely awanting, the edges will 
look ragged, and the surrounding parts will be found detached. 
Ulcerations are now known to be a frequent result of acute inflamma- 
tion ; but there is some degree of ambiguity about the tissue primarily 
involved. Some allege that they exist in the glandular structure, 
others in the mucous follicles ; while there are some who assert that 
the ulcerations take place in the mucous surface generally. 

It is now well ascertained that some parts of the mucous mem- 
brane of the stomach and bowels are more liable to inflammation 
and ulceration than others. The inferior half of the ileum is the 
part most frequently found inflamed and ulcerated ; according to my 
experience, the colon stands next to the ileum, and it is an extra- 
ordinary fact that the jejunum is seldom affected. Why it should 
possess this remarkable immunity from disease, has never been 
explained. In a case of poisoning, from corrosive sublimate, the 
jejunum was in a healthy state, while the stomach, the lower part of 
the ileum, the colon and rectum, were affected most severely, even 
to the destruction of the mucous surface, and thickening of the other 
parts of the intestine, the peritoneal coat only remaining sound. 

In proceeding to examine a piece of intestine, it should be care- 
fully cut open with a blunt-pointed pair of scissors, and, after the 
exudation is observed, the parts should be washed in water, till the 
mucus is removed from its surface. On some occasions we shall see 
numerous dark-coloured, distinct points, somewhat elevated, with 
a depression in the centre, which are the mucous follicles enlarged;* 
in some places a number of these points will be seen to coalesce, 
sometimes in a circular space, but in general they are more of an 
oblong shape. The surface is elevated, and sometimes spongy ; and, 
upon making a section through this part, it will, in general, be found 
that the sub-mucous tissue is principally involved in the disease, and 
occasionally also the muscular tunic. On looking at the surface 
through a glass, ulcerations will be discovered. This appearance is 
most frequently observed in the lower part of the ileum and caput 
caecum, in children who have died of bowel complaints. 

Occasionally numerous distinct points will be observed, as if a 
penful of red ink were spattered over the surface of the mucous 
membrane ; this I imagine is occasioned by an exudation of blood in 
the follicles, which are thereby distended. It is also noticed by 
Billard, to whose work upon the diseased conditions of the mucous 
membrane the reader is referred for much useful information, as well 
as to the 1st and 2d vols, of Andral's Clinique.t 

* There is a preparation in my museum, showing the mucous follicles of the 
colon so large that many of them would admit a swan-shot. The colon is con- 
tracted. The patient died after a surgical operation. 

1 Since the publication of the first edition, M. Andral has favoured the profession 
■with a work on pathology, which cannot fail greatly to advance the interest of 
medical science. The work is divided into two parts— the first treats of general, and 
the second of special pathological anatomy. There is, perhaps no individual so well 
qualified to undertake such a laborious task as M. Andral. He is not only placed, 
by universal consent, at the head of the French pathological school, but, 1 believe, 
had the scientific medical men of Great Britain been polled, they would, with one 
voice, have confirmed the choice of his own countrymen. Few have had such 



OF THE STOMACH AND BOWELS. 257 

On other occasions, ulcerations are observed, of a circular or oval 
form, with defined margins, attended by loss of substance, not only 
of the mncons membrane and the snb-mncous tissue, but extending 
into the muscular coat, which may be seen in different places in a 
ragged state. In addition to this the mucous membrane is some- 
times excavated to a considerable extent. The ulceration often 
destroys the greater part of the muscular coat, so as to aifect the 
peritoneum, which will then be found thickened and inflamed; the 
external surface being either covered with lymph, or looking like an 
excrescence of a dark red colour. Occasionally, when ulceration 
attacks the mucous coat, the sub-mucous tissue and the muscular 
coat become infiltrated with lymph, producing a thickening of the 
rest of the intestines, as if it were intended to strengthen the part, 
and prevent rupture. When ulceration first attacks the muscular 
coat, it would appear that an effusion of lymph takes place in the 
outer cellular tissue, in which case it is difficult to separate the peri- 
toneum from the muscular coat at the diseased part. Occasionally, 
indeed, the ulceration extends through all the tissues, allowing the 
escape of the contents of the bowels into the abdomen. Sometimes 
we observe distinct ulcerations on the mucous surface, inclining to 
the circular form, which are considerably elevated above the sur- 
rounding parts, resembling carbuncles, and having an appearance as if 
Ihey were to throw otf a slough. Upon making a section of the in- 
testines through the centre of one of these ulcerations, the cellular 
substance, and a part of the mucous coat, will be observed to be 
much thickened, and occasionally of a dark brown colour. Ulcera- 
tions are sometimes circular, at others oval; sometimes they run in 
lines, and, on other occasions, are observed to be irregular in shape. 
In size they vary from that of a millet-seed, to be so extensive as to 
occupy a larger space, sometimes the whole intestine. [This hyper- 
trophied and ulcerated condition of the glands of Bruner and Peyer, 
is the dothinenteritis of Bretonneau and others, which we have 
tdy described in* the section on typhoid fever. It is, also, the 
iieiiu ui Dr. S!ok«-s, and Borne other pathologists. ] In general ulcera- 
tions of the colon air more irregular in Bhape and size, than of any 
other part of the intestine. In some instances, ulcerations are sur- 
rounded by indurated margins, in others the mucous membrane seems 
to be merely removed. I 'let-rations in the small intestines are, for the 
most part, found in that portion of the tube most distant from the 

: examining the physical changes produced by diseased 

i fie we i are lobe found who could giye such graphic ne- 

script ions. He has conducted himself wiih great fairness towards iii- pathological 

Bnd those who have followed similar pursuits, will agree wiin mi' ihai ins 

• 1 -- 1 1 r. mp of truth. A faithful translation ol this excellent work 

'ill" joint production •>! Drs. Townsend and Wwt,of Dublin. 

i are not familiar wiih tin- Preach language, may feel obliged i<> these 

nen for putting such a work into their bands—a work which, from the siylc 

m which it has t a brought out, will oot, I fear, remunerate the translators. It la 

worth a thousand volume a literary compiler. It looks very suspicion! 

w highly commendatory of Ins own work in the journal or which Dr. 

• i another ol as contrary a eharactei of thai of Andral, Had 

in writer, I would have l< n him to fight W\s own battle with the 

, I think it desirable thai the selfish ihonld 

■:.rown U a Mur upon a Whole naiioii. 



£58 INFLAMMATION OF THE MUCOUS 

mesentery. In the colon they are sometimes seen to rnn in the 
course of the transverse bands, which ars greatly thickened and in- 
durated, while the mucous membrane may be partially or completely 
removed. Occasionally these ulcerations have a red appearance, or 
are tinged of a yellow or greenish colour by the fasces or bile, and are 
surrounded by a great number of red vessels; but in other instances, 
they present a blanched appearance; which last will be principally 
observed in cases where there has been a great discharge by stool. 
In many instances, the part of the intestine which is already ulcer- 
ated will show few or no red vessels, while other parts that are only 
advancing to that condition display intense arborescent vascularity. 

Ulcerations produce contractions of the calibre of the whole tube; 
but this is rare, unless the whole mucous surface be involved in the 
disease. It is not exactly the ulceration which produces the con- 
traction, but an effusion of lymph into the other coats and cellular 
tissues, causing considerable thickening. Occasionally we see the 
mucous membrane intensely red and thickened, partly from inflam- 
maiion, and partly from infiltration; and in one or two places pre- 
senting a seared appearance, as if it had been touched by a red-hot 
iron ; it looks somewhat puckered and very dark coloured, and some- 
times the neighbouring part is slightly mottled, as if from white 
granulations; but this is a rare appearance, yet I have seen it on 
several occasions, and always in the stomach. 

An ©edematous condition of the sub-mucous tissue is occasionally 
the result of acute action in the mucous membrane: but it may be 
also found in cases of general or partial dropsy. When the mucous 
membrane is sound, the effusion is not to be regarded as the result 
of inflammation. An effusion of air is also occasionally found in the 
sub-mucous tissue; but whether the result of inflammation, or a post- 
mortem change, was not satisfactorily determined till the appearance 
of cholera in Edinburgh. In several cholera cases, an extensive 
effusion of air was found in the sub-mucous tissue, when the dissec- 
tions were performed a few hours after death — too short a time to 
allow of such a post-mortem change. Mortification of the mucous 
membrane is also an occasional result of acute inflammation. This 
presents itself to us under two forms; the one is generally observed 
in the stomach in cases of fever, and in the last stage of phthisis, in 
which the mucous membrane is removed over a great extent of sur- 
face, leaving the parts of a dark colour; the other is observed in the 
intestine, and particularly about the caecum and ascending colon, in 
which the mucous membrane is lying loose, and in shreds of a very 
dark colour, and having the most offensive gangrenous odour. 

Inflammation of the mucous membrane, more particularly of the 
colon and rectum, terminates in a general thickening of the mem- 
brane and the sub-mucous tissue; and occasionally the muscular 
coat is also involved. The mucous surface is soft and spongy, some- 
times partially abraded a.nd very much thickened and discoloured; 
in some places of a bright red; in others of a dark mulberry colour; 
no distinct vessels can be seen, and the discoloration seems to be 
partly owing to infiltration of blood. This appearance is very apt 
to be confounded with mortification, and is principally observed in 



MEMBRANE OF THE STOMACH. 259 

the most acute form of tropical dysentery; but I have had many 
opportunities of seeing it in this country, in cases which ran their 
course in from eight to fourteen days. In some of these the intes- 
tine is more than the eighth of an inch in thickness — the preparations 
are preserved in my museum. 

Sometimes the mucous membrane of the colon and rectum, to- 
gether with the muscular coat and sub-mucous tissue, are seen simply 
in a state of hypertrophy, to a great extent, which appears to me to 
be the result of former inflammatory action ; many of the subjects 
had been in warm countries, and had suffered from dysentery. 

It is well known that ulcerations, with considerable loss of sub- 
stance, undergo the healing process, and that for some time after- 
wards the parts so restored may be distinguished by an appearance 
of cicatrization, which pathologists are well acquainted with, and 
which is best observed in old cases of dysentery. A beautiful pre- 
paration showing these appearances, is in my museum. 

[5. Tubercles. The whole internal surface of the intestines is some- 
times studded with small white bodies, which are, in fact, follicles 
filled with tuberculous matter. They seldom exceed a pea in size, 
and always have an orifice through which the matter may be pressed 
out. Andral, however, regards these appearances as mere follicles, 
altered both in respect to nutrition and secretion.] 

Sometimes we see tubercles in the mucous membrane itself, with 
more or less extensive ulceration ; or the tubercles are found in the 
sub-mucous tissue, with ulcerations on the mucous surface, in various 
stages, and extending from the tubercular elevations. These ap- 
pearances are also principally seen in the colon in cases of phthisis. 

There are, no doubt, many other appearances, which are produced 
by inflammatory action in the mucous membrane; but a minute de- 
scription of all would require a separate treatise, and is not consistent 
with the plan of this work. 

Competent judges may deem the above description very imper- 
fect. 1 can only say it is drawn from nature, and it will afford me 
much pleasure to demonstrate its general correctness, by showing the 
preparations and drawings in my collection, from which it is taken. 



GASTRITIS. INFLAMMATION OK THE MUCOUS MEMI1KANE OF THE 
STOMACH. 

It is difficult to determine the meaning of most writers when they 
speak of gastritis. Some use this term to indicate inflammation of 
the peritoneal coat of the stomach, which is a rare disease; others, the 
mucons. A great deal <•! obscurity also prevails in different works, 
from tin- use of iIk' terms phlegmonous and erysipelatous, adhesive 
and erytheroatic, winch 1 shall therefore be careful to avoid. 

tstritis, I mean to express an inflammation of the mucous 
membrane of the stomach, frequently involving the sub-mucous 
tonally the muscular coat. 

Inflammation of me mucous membrane of the stomach exists in 
various degrees of intensity, from the most acute to the slightest sub- 



260 INFLAMMATION OF THE MUCOUS 

acute form; and it may also be chronic. Acute inflammation of the 
mucous membrane of the stomach is a rare disease ; it often exists in 
a sub-acute, bnt more frequently in a chronic form. 

Symptoms of gastritis. — There is a burning pain in the region 
of the stomach, increased on pressure; a constant desire for cold 
drinks; which are immediately vomited ; nausea, and inclination tp 
retch, are incessant ; the heat over the surface of the epigastric region 
is considerable, while the extremities are perhaps cold. At the same 
time the patient frequently complains of sore throat; and upon ex- 
amination, the fauces will be found inflamed. Hiccup is a trouble- 
some symptom. The state of the tongue cannot altogether be de- 
pended upon ; in general, however, it is very red at the tip and round 
the edges; loaded, and occasionally very rough in the centre, and 
towards the root ; sometimes, in long standing chronic inflammation, 
it is red, glazed, and smooth ; although I feel persuaded that this last 
condition of the tongue takes place more generally when the intes- 
tines are inflamed and ulcerated, than the stomach. The breathing 
is anxious and quick, and the patient restless; the pulse is small, and 
the prostration of strength soon becomes very great ; the countenance 
is expressive of great anxiety, and the individual makes great com- 
plaint. Towards the termination of the disease, the features shrink, 
and the patient lies upon his back. The matter vomited in the early 
stages, consists of the fluids taken into the stomach, occasionally 
mixed with bile and some mucus; but at last the black vomit takes 
place. The bowels are generally constipated. 

There is scarcely any acute disease which so frequently exhausts 
the powers of life, and hence it is said that the symptomatic fever is 
of a typhoid type. It happens occasionally, however, that the symp- 
toms are exceedingly mild, when the disease has been produced by 
mineral poisons; and appearances denoting great danger, do not 
come on till within a (ew hours of the fatal termination. This was 
particularly well marked in a soldier of the 17th foot, who swallowed 
two drachms of the oxymuriate of mercury, and who died unex- 
pectedly eight or ten days afterwards on the close stool ; having been 
able to get out of bed, and walk unsupported. 

It has been already stated, that the acute form of this disease is a 
very rare occurrence, and that it more frequently exists in a sub-acute 
and chronic form ; and we see these most frequently in fevers, in 
dyspepsia, and in the last stage of phthisis. 

Causes. — This disease is produced by any of the common causes 
which occasion inflammation ; by wounds and contusions, as well 
as by poisons and other acrid substances taken into the stomach; 
also by too great indulgence in the use of ardent spirits: it some- 
times follows in the train of other diseases, as cholera morbus, &c. 

Appearances on dissection. — On opening the stomach, a consider- 
able quantity of thick, tenacious mucus will be observed; and the 
mucous membrane itself will be found in one or other of the condi- 
tions already noticed in the general description. It may be mentioned, 
that the appearances produced by poisons so closely resemble the 
lesions occasioned by ordinary inflammation, that no distinction can 
be made; and the nature of the case must rest upon the fact of poi- 



MEMBRANE OF THE BOWELS. 261 

son being found, and its powers ascertained. [Ulceration is rarely- 
met with in acute gastritis, and when it does take place, it seldom 
penetrates as far as the muscular coat. When the follicles are in- 
volved, they resemble small, reddish pimples. Gangrene of the 
stomach is of still more rare occurrence.] 

Treatment. — Bleeding copiously and frequently must be had re- 
course to, and at short intervals; there is no disease which requires 
a more decided use of the lancet. The application of leeches in con- 
siderable numbers may also be found necessary, either after the 
inflammation has been somewhat subdued by the lancet, or when 
the physician is afraid that it is too late for general bleeding. Blis- 
ters are, of course, to be employed in severe cases. Laxative med- 
icines are also necessary; but it is needless to administer them till 
the diseased action is considerably subdued, as they will increase the 
already too irritable state of the stomach; therefore, in the first in- 
stance, we are to endeavour to open the bowels by injections. Opi- 
ates are very useful; but it is necessary to caution young practition- 
ers against the routine practice which is too generally followed, of 
trusting to opium whenever there is irritability of the stomach. 
When opium is given, it is often advantageous to exhibit it in the 
form of pill combined with calomel. The warm bath, and hot fo- 
mentations to the part affected, are means which must not be neglect- 
ed; and it is necessary to restore and support the natural heat of the 
extremities. 

During convalescence, the diet must be carefully attended to, and 
should merely consist, for the first day or two, of arrow-root or fine 
oatmeal gruel. 



ENTEIUTIS. — INFLAMMATION OF THE MUCOUS MEMBRANE OF THE 
BOWELS. 

hrvLAMHATiOB of the mucous membrane of the bowels, varies 
perli.ips more in its external Bigns than that of any other structure 
in the body, and for the mosl pari its attack is most insidious. The 
most frequently met with in a sub-acute or chronic form; 
even when acute, the symptoms arc sometimes exceedingly mild ; 
Mid this lakes place occasionally in cases where we subsequently find, 
on dissection, not only the must extensive inflammation, but ulcera- 
tion; which will be more fully shown when treating of dysentery. 

Symptoms. — The combination of symptoms denominated (ever, 
take place with more or less intensity; in fact, as already shown, in- 
lamniation of this tissue is the cause of many of the fevers which 
prevail in all climates. I'ain is often very slightly felt, in compari- 
son wuh thai which generally attends peritonitis; when the small 
intestines are affected, the pain is experienced more about the um- 
bilicus than m any other region ; cold drinks aggravate it, as well 
as any indigestible substance taken into the stomach. The pulse is 
found in very different states even during the same day; itis fre- 
quently qoick, but not in general so hard as m peritonitis. The skin 
is generally hot and parched during the day and night, hut towards 



262 INFLAMMATION OF THE MUCOUS 

morning some degree of moisture tnkes place, and it is then only - the 
patient enjoys comfortable sleep. Thirst is often very urgent. 

Tympanitic distension causes considerable suffering to the patient, 
and aggravates the constitutional symptoms. The tongue is not 
altogether a sure index of the state of the mucous membrane, as I 
have seen it perfectly clean and natural in colour, or foul without 
redness, when dissection revealed most extensive inflammation. But 
in general, the tongue will be found to be more or less red at the 
tip, and round the edges, however much it may be loaded in the 
centre; sometimes it is altogether red, and looks raw, and perfectly 
smooth like varnished leather ; when it is unusually red, I look upon 
it as a certain indication of very considerable irritation, or of some 
degree of inflammation or ulceration of the mucous membrane of 
the bowels. When the superior parts of the tube are diseased, there 
is more or less nausea and tendency to vomit ; when the inferior 
parts are implicated, we find pain in the iliac regions, and in the course 
of the colon, with more or less diarrhoea, and considerable discharges 
of flatus; and when the colon is severely affected, there is that twist- 
ing pain in the bowels, which, in medical language, is denominated 
"tormina ;" it comes on in paroxysms, with intervals of perfect ease. 
The patient complains of it every hour or half hour, and even 
at shorter intervals, and it is always followed by an irresistible de- 
sire to go to stool. When the rectum is involved, there is considera- 
ble straining, and the patient can scarcely be induced to leave the 
close-stool, and yet he passes nothing but a little mucus mixed with 
blood, or a small quantity of scybalous matter, with some flatus. 

Every experienced medical man, upon reading these passages, will 
perceive that I have been describing the symptoms of diarrhoea and 
dysentery; but my wish at present is to describe inflammation of the 
mucous membrane of the intestines generally, as the peculiar nature 
of the discharges by stool, which constitute diarrhoea and dysentery, 
do not always attend inflammation of that membrane. 

Women, after delivery, are sometimes seized with this affection ; 
and some imagine that when peritonitis takes place in that condition 
of the system, it is always owing to the extension of the inflamma- 
tion from the mucous tissue. But although sometimes the case, this 
cannot be assented to as a general rule. An instance of pure inflam- 
mation of the mucous membrane of the small intestines lately occur- 
red to a woman, after an abortion at the fourth month, which resisted 
the most active practice, and terminated fatally. On dissection, traces 
of active inflammation of the whole membrane were discovered, 
which several days maceration in water did not destroy, and a por- 
tion of it, which is put up in spirits in my museum, still retains its 
red colour. There were also a great number of abrasions, which, 
had the woman lived a few days longer, would have been converted 
into deep and extensive ulcerations. Another fatal case occurred in 
the practice of a friend, after delivery at the full period. In this 
lady, the disease was apparently produced by a large quantity of 
grapes she had eaten with the skins and stones, which were found in 
different parts of the intestinal canal. But in neither of these cases 
did the peritoneum suffer. 



MEMBRANE OF THE BOWELS. 263 

Treatment.— If the disease be very acute, the lancet must be 
used; but the cases which usually fall under our notice, will yield 
readily after the application of a dozen or eighteen leeches to the 
abdomen, together with the warm bath, fomentations, and the gen- 
tlest laxatives. If there be much tympanitic distension, injections 
witli a small quantity of turpentine, or with an infusion of tobacco, 
will be found very serviceable. Opiates are useful, and the best 
preparation perhaps, in such circumstances, is Dover's powder. We 
shall seldom be obliged to apply blisters, except in very acute cases; 
but the disease is often mitigated by the application of hot oil of tur- 
pentine, or a mustard poultice, which is to be removed in a short 
time, so as not to occasion vesication. Attention must be paid to 
diet and clothing, particularly during convalescence. 

Chronic inflammation of the mucous membrane. — I have fre- 
quent occasion to see cases of long standing inflammation of this 
tissue. They will be often found connected with some cutaneous 
eruption, as lepra, psoriasis, &c, or with ulcers on the extremities. 
It will be observed, that the patients enjoy best health when the 
eruptions are most severe, or the ulcers most troublesome and at- 
tended with copious discharge. These circumstances were first 
forced upon my attention, upwards of twenty-five years ago, in a 
warm climate, and subsequent observations have tended to confirm 
them. 

These pathological considerations would seem to demand a differ- 
ent treatment from that generally pursued in diseases of the skin, as 
well as in many ulcers on the extremities, and will show surgeons 
the propriety of attending to medical pathology, so as to enable them 
tu treat even a common ulcer. I do not mean to assert that all ulcers 
are produced by this cause, but that many are so, I have no doubt; 
and it is m cessary to point out the circumstances which will enable 
■ young practitioner to distinguish them. When a person affected 
with an ulcer, says that he feels in better health when the ulcer is" 
open than when it is healed, we may suspect that there is some in- 
ternal disease ; but when we likewise find his skin harsh, his thirst 
increased, the appetite impaired, or fastidious; together with some 
nausea; il there be uneasiness, fulness and oppression in 
i bdomen, increased after taking a cold drink, or after meals; if 
rnately affected with constipation and diarrhoea, the eva- 
cuations being fetid and discoloured ; if the tongue be loaded, and of 
iur ai the t.p and round the edges, or universally red, or 
loaded, bul covered with large and elevated papilla at the root; if 
any of these symptoms exist, even in a slight degree, along with the 
nicer, or become increased after it is healed, we may rely upon it, 
thai the mucous mi mbrane of some part of the intestinal tube is af- 
fected. 

Dreatment. — In the cases I have described, whether attended by 
I'M or eruptions,] have sometimes Been the most striking 
lit f r i mm general bleeding; but this is nol often necessary, unless 
the eruption be attended with much inflammation of the skin. In 
hi, leeches applied every second or third day about the umbili- 
cus, and p pi Ued for .some tune, together with the general warm 



264 [DIARRHCEA.] 

bath, gentle laxatives, a bland dry diet, never allowing the patient 
to eat a large quantity at a meal, will be productive of great benefit. 
Subsequently contra-irritation, produced by the tartrate of antimony 
ointment, is to be used ; but I shall speak more fully upon the sub- 
ject, in the second volume, when treating of cutaneous diseases. 



DIARRHCEA. 

A person who has frequent liquid stools, is said to have a diar- 
rhoea, which may exist with or without fever. The evacuations are 
almost always fetid, discoloured, watery, or somewhat slimy, con- 
taining more or less feculent matter. Sometimes, on examining a 
watery or a slimy stool, small, round and hard masses of faeces may 
be found. Diarrhoea may also be attended with thirst; griping pains 
in the belly, which become relieved for a short time after an evacu- 
ation; and there is frequently tenesmus. 

[Diarrhoea is divided into several varieties, according to the cha- 
racter of the evacuations. In most instances, these consist at first of 
feculent matter more or less diluted with the secretions of the liver 
and intestines; and it not unfrequently happens that the disease runs 
its course by thus expelling some irritating ingesta; as, the skins or 
seeds of fruits, or the fruits themselves, indigestible meats, acid drinks, 
and, in fact, any gluttonous indulgence. This form of disease is called 
feculent diarrhoea, and often works its own cure. 

Diarrhoea is often induced by different causes; — sudden changes 
from warm to cold weather, or exposure in damp and chilly situa- 
tions while in a state of perspiration. Cold bathing also at times 
induces diarrhoea; to which also may be added, the violent passions 
or emotions of the mind. 

The preceding causes act more powerfully under certain circum- 
stances; such, for example, as previously impaired digestion, various 
diseases of the liver, or other digestive viscera, &c, &c. It is obvious, 
also, that these latter causes may act independently of the alimentary 
substances received into the stomach; whence practitioners as well 
as nosologists describe several forms of diarrhoea, as the mucous, the 
bilious, the lienteric, and some others. 

In mucous diarrhoea, the evacuations, as the name implies, consist 
chiefly of an excessive secretion of alvine mucus, more or less mixed 
with feculent matter, sometimes ropy and tenacious, and occasion- 
ally highly offensive. These appearances have not unfrequently 
been mistaken for worms. The bilious form of this disease is most 
common in hot climates, and not uufrequent in our own latitudes. 
The bile, which is thus poured out, is in great quantity, and in some 
instances almost as unmixed and inodorous as when it came from 
the liver. 

In the disease called lienteria, the aliments pass rapidly through 
the bowels and are ejected from the rectum, undigested and unal- 
tered. Thus meats and drinks, the very milk which has been taken 
by children, even water itself, are scarcely swallowed before they 
create a sense of pain or uneasiness, and are in a short time evacu- 
ated. 



[DIARRHCEA.] 265 

In other cases, diarrhoea is a mere result of long continued consti- 
pation, the one extreme. ending in the other; and the discharges may- 
be kept up for days and even for weeks by hardened faeces, which, 
lodging in the cells of the colon, induce a constant irritation and ex- 
cessive secretion of mucus. 

It not unfrequently happens that several of the preceding condi- 
tions are combined in a single attack. Thus, a diarrhoea, which 
begins with profuse feculent discharges, suddenly assumes the bilious 
form, to which the mucous secretions follow from prolonged irrita- 
tion of the lining membrane. These morbid fluids are sometimes 
tinged with blood, which may become profuse from simple exuda- 
tion, as described in a former chapter, constituting what has been 
called sanguineous diarrhoea} a name, which., in common with 
many others, is derived from a symptom rather than a pathological 
condition. 

Again, the evacuations are composed, in large part, of coagulable 
lymph, which, secreted by the inflamed or irritated mucous surface, 
assumes the shape of the intestine itself, and is thus thrown off in 
hollow, membranous cylinders. This is \\\o. fibrinous diarrhoea oi 
the systems, and which we have more fully described under (he head 
of cholera. In some instances, these membranous secretions are 
thrown off in patches or in masses, which may be mistaken for undi- 
gested food. 

Diarrhoea in all its varieties, is accompanied by prostration of 
strength, variable appetite, or a longing for improper and indigesti- 
ble aliments. The onset, in severe attacks, is often accompanied by 
fever; but this symptom may be as speedily relieved by the sponta- 
neous or assisted evacuations of the bowels, and is therefore of short 
duration. 

It will follow, from the preceding remarks, that simple diarrhoea is 
a symptom consequent to several very different pathological condi- 
tions ; irritation of the liver ; irritation or inflammation, of a part or 
the whole of the mucous membrane, disease of the follicles, or of the 
glands of I'eyer, &e., and we often meet with examples in which 
all these tissues appear to partake simultaneously of the same irrita- 
tion ) 

fment. — From the pathological description given above, it 
will i>m Been that the treatment must be considerably modified, If 
the affection be produced by the applicatiou of cold to the surface, 
Ihe warm hath, a dose of Dover's powder, and subsequent attention 
to clothing, ami particularly preserving the heat of the extremities, 
will be all that is required. IT by unwholesome food, it must be 
led for the future; gentle laxatives must he given to hurry the 

_•'• of the offending matter thrOUgh the dowels, followed l>v all 

opiate. If by diseased biliary secretion, which is to he recognized by 
the existence ol nausea, or even vomiting of considerable quantities 
of I ile, together with the passage of bilious stools, which, perhaps, 
will produce a pungent sensation in the rectum, and considerable 
•mis, a little calomel and opium may he prescribed, followed by 
r.p "i,i, or any other salts, largely diluted with water, 

together with OOplOUl drinks of gruel, or barley water, or any oilier 
23 



266 [DIARRHCEA.] 

bland diluent. If from constipation, which can only be recognized 
by examining the stools, that state must be removed by gentle laxa- 
tives, frequently repeated, conjoined with opium or hyoscyamus, 
and assisted by unstimulating injections. In this case, the warm 
bath is also serviceable; and after the bowels are fairly cleared of 
the hardened fasces, the irritation is to be subdued by an opiate. If, 
in any of these cases, there should be considerable pain in the belly, 
with fever and a hard pulse, bleeding may do good, and can rarely 
do harm. But should diarrhoea depend on inflammation of the mu- 
cous membrane, or should inflammation supervene during the pro- 
gress of the disease, bleeding, either general or topical, ought to be 
employed, if the means above recommended do not succeed. Cases 
have occurred to me, where nothing else was necessary after ab- 
stracting blood from the arm, but which had previously resisted all 
the ordinary remedies for many days. If, notwithstanding the em- 
ployment of these means, the patient be not relieved, or if he be so 
weak as to make us anxious to save blood, an injection of tobacco 
may be perhaps substituted. Opiates, attention to the diet, and con- 
tra-irritation, must be had recourse to. If in any case there be much 
tenesmus, a teaspoonful of laudanum, mixed in an ounce or two of 
gruel, is to be thrown into the rectum. 

It would appear that Hume, the celebrated historian, died from 
ulceration of the bowels, which was not recognized by his physi- 
cian.* 

[Diarrhoea is extremely prevalent in the United States, owing to 
two principal causes — the proverbial changeableness of the climate, 
and the profusion of fruit. When, as often happens, it can be traced 
to over-indulgence in fruit, laxatives of magnesia, or of calomel and 
rhubarb should be first given; after their operation, alterative doses 
of calomel and opium, or of camphor-water and nitric acid,t are 
highly serviceable. This preparation of camphor has proved, in my 
hands, more efficacious than any other single remedy whatever. It 
is sometimes injured by adding too much of the acid, which should 
seldom exceed the small quantity directed in the following prescrip- 
tion : — R. Aquae camphorae, 5iv; Acid, nitric, gtt. iv; Tinct. opii, gtt. 
xl. vel Ix. — Of this a tablespoonful is to be given every two hours to 
an adult, and in proportion, to children. — The chalk julep, especially 
where acidity is present, is also an excellent medicine. J The infu- 
sion of oak bark, or nut-galls, small doses of acetate of lead or sul- 
phate of zinc, with or without opium, will all in turn serve a good 
purpose. 

Very small doses of calomel, the sixth or even the eighth of a 
grain, given assiduously every hour or two hours, will occasionally 
check a troublesome diarrhoea; so also a pill of alum and sulphate 
of iron, the mineral acids, &c. Mr. Hoblin, of London, recommends 
in strong terms, rhubarb powder which has first been burnt black in 
an iron pot or crucible, and then diffused in portwine. 

* The account of his symptoms and feelings, in his own words, is very interest- 
ing.— Vide History of England, vol. i., Introduction, p. xix. 
[t See Appendix, Prescription No. 44.] 
[* See Appendix, Prescript. No.] 



BOWEL COMPLAINTS OF CHILDREN. 267 

Too little attention is generally given to injections. These act 
promptly ; and the best of them are composed of laudanum or mor- 
phia with starch mucilage; or four or six grains of the sulphate of 
zinc, dissolved in five or six ounces of water or flaxseed tea. 

Whenever a diarrhoea becomes intractable to these or other modes 
of treatment, a certain cure can often be effected by a short voyage 
to sea, or even in a river steamboat. Carriage exercise also contri- 
butes greatly to the cure of obstinate diarrhoea. 

The diet should consist of arrow-root, sago, or tapioca, or of lime- 
water and milk in equal parts. Rice is also unobjectionable; and for 
common drink, rice-water and gum-water are best. An admirable 
diet consists of cold milk which has been first boiled. This can be 
thickened if desirable, with rice or common flour. In our southern 
states, a dietetic preparation of parched rice, flour, and milk, is much 
in vogue, and I have resorted to it with gratifying results.] 



BOWEL COMPLAINTS OF CHILDREN. 

The pathological observations already made in the last sections 
equally apply to the bowel complaints of children. In the course of 
practice, it is distressing to see so many children carried to the grave 
from a diseased condition of the alimentary canal; although there 
is no class of complaints, which, when taken early, and treated ac- 
cording to good pathological principles, are more under control. 
They frequently terminate by producing marasmus, and a complaint 
which I have presently to notice, under the name of tabes mesen- 
terica. 

Much mischief is occasioned by the method too generally adopted 
immediately after birth. A child is scarcely dressed, when a tea- 
spoonful of castor oil is wantonly forced down the throat; or a great 
deal of Btlgar and water is given, for the unnecessary purpose of 
piirL'in-.' away the dark matter which collects in the lar^e intestines 
dnriiiL.' tie- last two or three months of in nt'-riiie life. We ought to 
i i no hurry to expel this matter, as if it were a virulent poison, 
iIk- retention of winch will <■ irry death into the very vitals. We fre- 
quently see fatal bowel complaints produced by this cause, and it is 
imi uncommon thing to discover ill at drastic purgatives have bgen 
employ I. Not long ago, I was called to see a child under a fort- 
night old, who was taking half a grain of calomel and two mains of 
scammony twice a-day, although it had from fifteen to twenty stools 
during the course of twenty-four hours, notwithstanding the exhibi- 
tion of occasional doses of chalk mixture. In Bucfa cases, the drastic 
purgatives are given in the first instance to "clear out the bowels," 
and afterwards persevered in u tc improve the evacuaiiona." 

Another source <>l the bowel complaints of children, proceeds from 
the absurdities constantly committed with respect to their food. 
i alter the castor oil has ben exhibited, the nurse insists upon 
giving food, consisting "i thick gruel, which the stomach is totally 
Incapable of digesting; flatulency is the consequence; they cry; and 
then the none by as carminative for relief, which produces 



268 BOWEL COMPLAINTS OF CHILDREN. 

ease for a time, but by inducing constipation, renders another dose 
of castor oil necessary; this, in its turn, frequently gripes. This the 
nurse attributes to wind in the stomach and bowels, and again thick 
indigestible food is given to drive out the wind, which, in its turn, 
again requires the Dalby. In this manner the functions of the sto- 
mach and bowels are too often impeded, and not only impeded for 
the time, but the children are rendered ever afterwards liable to com- 
plaints in the stomach and bowels. 

Daily do I see the advantage of pursuing an opposite plan with 
new-born children. No laxative medicine should be given, unless 
an infant suffers from distension of the abdomen. Should this be 
the case, the old plan of using a suppository, or a twisted piece of 
paper, will in general answer every purpose ; but if it should not, 
then a gentle laxative may be given by the mouth, and the best is a 
small teaspoonful of castor oil, or about three grains of Henry's 
magnesia. With respect to food, an infant ought not to have any- 
thing more substantial than well-made whey, or milk and water, till 
it can procure food from its own natural fountain. 

Some children are so constituted, that, do what we will, they 
have more than the natural number of stools, and yet they go on 
growing and thriving in a remarkable manner. In such cases, little 
or nothing ought to be done, because there is good evidence that 
there can be no serious disease. Again, some children are naturally 
constipated, and yet they thrive ; in such cases, also, much interfer- 
ence is unjustifiable, beyond changing the milk, or exhibiting a little 
manna. A healthy child, at the breast, ought, in general, to soil from 
four to six napkins in the course of twenty-four hours; the evacua- 
tions, after the first fortnight, should look like well-made mus- 
tard, with, perhaps, white specks here and there ; it should have a 
sour smell, and possess no fetor. In disease, the stools are sometimes 
green and watery; sometimes yellow and watery; sometimes brown 
and frothy, or while and frothy, as if mixed with yeast; and also, 
whitish and hard, like half-baked clay; occasionally bluish, and very 
often mixed with slime, or are altogether slimy. When the stools 
are bluish, and particularly when whitish, like half-baked clay, they 
are very adhesive, and expelled from the bowel with difficulty. 
Instead of having the natural sour smell, they are like the stool of 
an adult; or they may have a still worse smell, sometimes compared 
to rotten eggs, at others to train oil ; and occasionally even still worse, 
like that which emanates from -a gangrenous sore. Green and 
brown stools are generally watery, or mixed with mucus, and are 
occasionally discharged, when the child is held out, as if they came 
with violence from a squirt, and are often preceded by considerable 
signs of suffering. 

The bluish and the whitish stools are generally few in number, 
but are attended with consequences fully as dangerous to the infant, 
as they terminate by producing diarrhoea of the most intractable . 
nature. In many of these cases, the diarrhoea alternates with con- 
stipation; and occasionally there is so much irritation in the rectum, 
that prolapsus ani takes place, attended with great suffering. 

Many children go on thriving remarkably well, having a regular 



BOWEL COMPLAINTS OF CHILDREN. 269 

state of bowels till they are weaned, when, from the sudden change 
of food, a serious disturbance is occasioned in the stomach and 
bowels, announced by vomiting and purging or by purging alone, 
the stools consisting at first of feculent matter, then mixed with 
mucus, and perhaps tinged with blood ; and subsequently of a white 
serous fluid, like dirty water, which is discharged suddenly, and 
squirted with violence from the bowels. Children so affected are 
said to have the " weaning brash," which has some resemblance tc 
the true cholera. 

Treatment. — If the disease be produced by the injudicious use 
of laxatives, these are to be discontinued or diminished in quantity 
and conjoined with a slight opiate, as, for instance, a quarter or half 
a drop of laudanum in a teaspoonful of a solution of manna. If 
from indigestible food, it is to be withdrawn, and the child must sub- 
sist entirely upon the breast. If there be good evidence of its own 
milk disagreeing with it, another nurse should if possible be procured. 
Green stools are often occasioned by the exhibition of calomel, 
which is too frequently allowed to be prescribed by nurses them- 
selves. The yellow watery stool, and the brown watery stool, often 
announce an excess of bile ; while the bluish and whitish stools, but 
particularly the latter, indicate a diminished quantity of bile. In the 
former cases, a little thin arrow-root, one small dose of calomel, 
followed by a little castor oil, and an occasional teaspoonful of chalk 
mixture, together with the warm bath, will be all that is required. 
But in the latter cases, five or six half-grain doses of calomel, or one 
grain doses of hydrargyria cum creta, given either at night or til the 
morning, followed by an occasional small quantity of castor oil, and 
attention to the diet, will be sufficient to put the child in a fair way 
of doing well. According to my experience, a mercurial preparation 
is particularly necessary when the stools have the peculiar disagree- 
able odour? formerly described. If much mucus be discharged, 
particularly if tinged with blood, and expelled as if it came from a 
•quirt; if there are fever, restlessness, peevishness, and thirst, and 
particularly if the child cries much and emaciates, medical men 
should be upon their guard ; for if inflammation of the mucous mem- 
brane do not already exist, there are evidences of its being threatened. 
Solid food should be carefully avoided; and, if the child be already 
weaned, u should be offered nothing but whey or ass's milk. The 
warm bath if to be used morning and evening; and I have found 
powders composed of calomel, aromatic powder, and Dover'spowder, 
with or without rhubarb, proportioned to the age of the patient, 
highly useful. To a child of three, months old, I would give half a 
gram of calomel, the same quantity of Dover's powder, and two of 

ttoraatic powder, every three, ibur v or six hours; to a child under 

that age, i imewhat Bmaller quantity of Dover's powder may be 

liven, and it should be increased to those who are older. If the 

feverish symptom! Still continue, a leech should be applied, or a 

s tim u l ating embrocation rubbed upon the abdomen. It is always 

sale pro lie,- | () apply a laecfa early, which is not only justified, hut 

loii'iiy deman d ed, by the appearances on dissection, when the 
mucous membrane is seen, not only in a high state of inilammation, 



270 TABES MESENTERICA. 

but also of ulceration. My museum contains many specimens and 
drawings of such morbid changes. 

Sometimes we are not consulted till the little sufferer is greatly 
reduced, and it should be remembered that its vital powers may sink 
early, from the peculiar severity of the disease. In such cases, we 
must be guided by the expression and colour of the face, state of the 
pulse, and the temperature of the body. If the expression be subdued, 
the face pale, the features sharpened, the extremities and tip of the 
nose cold, and the pulse weak, a stimulant is instantly to be given, 
and the best one is brandy and water, proportioned to the age of the 
child ; it may be necessary to conjoin an opiate with the stimulant. 
The warm bath is also to be had recourse to. 



TABES MESENTERICA. 

This is a disease in which there are great emaciation of the whole 
body and enlargement of the abdomen. 

After the bowels have been for some time in an irregular state, 
the child is observed to fall off very much in strength ; the extremities 
and the face becoming much emaciated, while the belly is observed 
to be tumid ; the appetite is fastidious, sometimes ravenous ; there are 
great thirst, and frequent griping pains. A child so affected has 
some degree of fever, while another has no feverish symptom; but 
most commonly there is a febrile attack during the night, which 
goes off towards morning with perspiration. The abdomen feels 
doughy and knotty, at other times tense and tympanitic. At first 
the tumefaction is owing to flatus; but as the disease goes on, effu- 
sion takes place into the cavity of the abdomen ; there is constant 
purging, till at last the child dies exhausted, or is carried off by 
disease in some other part, commonly of the brain or lungs. 

Jlppearances on dissection. — On dissection we sometimes discover 
chronic peritonitis, with enlargement of mesenteric glands; but more 
frequently ulcerations of the mucous membrane of the bowels, the 
effect of long-continued sub-acute, or chronic inflammation. The 
whole of the internal surface of the colon is sometimes ragged; the rest 
of the coats of that intestine being, in general, very much thickened; 
at other times, the lower parts of the ileum and caecum are affected ; 
and occasionally ulcerations are seen in the jejunum, increasing in 
number, however, in the course of the ileum. 

Treatment. — The pathology of this disease appears not to be 
understood by the generality of practitioners. It is too often attri- 
buted to scrofula, merely because the mesenteric glands are known to 
be enlarged; therefore the muriate of lime is extensively employed 
by those who are calcined in old prejudices, and who are blessed 
with so much patience, that three years is not considered too long a 
period to wait for its good effects. The disease should be treated as 
one proceeding from inflammation and ulceration of the mucous 
membrane of the bowels, which will also be the best practice, should 
the disease be found occasionally to depend on chronic inflammation 
of the peritoneum. 



DYSENTERY. 271 



DYSENTERY. 

This affection is known also by the name of flux; when attended 
with a discharge of blood, bloody flax. 

Dysentery is generally divided into two varieties — acute and 
chronic. 

Symptoms of acute dysentery. — This form commences like a 
common diarrhoea, with griping pains in the bowels; frequent calls 
to stool, with an irresistible desire to strain ; the evacuations are 
sometimes fluid and copious, with the usual fetor; at others scanty; 
and whether copious or scanty, there is occasionally seen, particularly 
in this country, some hard scybalous matter, with mucus, sometimes 
streaked with blood, and very fetid. In warm climates it is rare to see 
scybalie; when there is feculent matter, it is very watery. After a 
stool, the patient feels more or less relieved, but soon another parox- 
ysm of pain frequently amounting to what has been denominated 
"tormina," takes place, and he may have a great many such attacks 
during twenty-four hours. In this country, for the first few days, the 
heat of skin is not much increased, nor is the pulse accelerated; 
the tongue is loaded, and generally red at the tip; the thirst is urgent; 
there is loss of appetite; considerable prostration of strength, and 
depression of spirits. 

After the lapse of two or three days, more or less, the patient com- 
plains of fixed pain in the hypogastrium, and in one or both iliac 
regions, which sometimes becomes very distressing; it is increased 
by pressure, and I have been able to trace it, on many occasions, along 
the track of the colon. Sometimes there is universal heat of skin; 
at others, the abdomen only will feel burning to the hand, whilst the 
rest of the body is cool ; nay, the extremities may be ice cold, and 
the patient may complain of frequent rigors. The evacuations from 
the bowels, at first feculent and copious, now become more frequent 
and scanty, consisting entirely of mucus, or of mucus mixed with 
I ; or they may be Mill watery, and of a dark brown colour, 
with portions ofslime here and there; or they may have the appear- 
of dirty water slightly tinged with blood, with now and then a 
little scy bals. The stools become more and more disagreeable in 
odour, till at lentil an experienced person will be able to recognize 
the smell to be dysenteric upon first entering the room. The tenes- 
mus is more distressing, together with a cramp-like feel in the thighs 
and legs, which is relieved after each evacuation ; it is with didiculty 
thai die patient can he persuaded to leave the close-stool, and lie 
down in bed. The secretion of urine is frequently suppressed, and 
tie' patient suffers a good deal of pain from that cause. Thirst in- 
prefi rred, from which the patient cannot refrain, 
although he knows it is bad lor him. The tongue is more, loaded 
and florid ; or u has by this tunc become dry and glazed. The skin 
is either parched, or covers I with copious perspiration, which, in the 
worst cases, doe - not appear to mitigate the symptoms, although sonic 

il it experienced in slighter instances. When the skin is univer- 
sally hot and parched, the puis.; in general will be found quick, full, 



272 DYSENTERY. 

and bounding, but when the extremities are cold, it will, perhaps, 
feel weak and thready ; yet, in some instances, the pulse is not much 
changed from its natural state, neither are the other symptoms 
troublesome, till within twenty-four hours of death. 

Sometimes the patient preserves some degree of appetite for a few 
days, but in the course of two or three hours, the articles of food are 
passed by stool in an undigested state. The patient emaciates quickly; 
the despondency increases; and, as the disease advances, his bodily 
weakness increases, till at length he is unable to obey the frequent 
calls to go to the close-stool. He lies upon his back, unable to move, 
and at length passes his stools involuntarily, which appear as if mixed 
with shreds of membrane; occasionally they resemble pea-soup, 
and sometimes are even like pure pus ; or they still continue to con- 
sist of mucus, more or less tinged : the bowel is constantly in a state 
of protrusion, and the fetor which emanates from the patient is almost 
intolerable. In warm climates, I have seen an appearance as if large 
portions of the mucous membrane had been thrown off in a state of 
mortification, and I knew one patient recover after such an event. 
Sir George Ballingall and others mention a similar circumstance as 
having occurred in their practice ; but recovery in this stage is almost 
out of the question. The pulse sinks ; the pain ceases ; and the mind, 
which perhaps has, hitherto, been quite clear, now becomes disturbed; 
a cold clammy sweat takes place, and death shortly closes the scene. 
Hiccup and vomiting are occasional symptoms; and, during the pro- 
gress of the disease, the symptoms frequently undergo remarkable 
remissions, which excite hopes of recovery. I have seen the strong- 
est men destroyed by this form of the disease in four days; but in 
general the case is protracted for two or three weeks. 

Syjnptoms of chronic dysentery. — This form is rarely met with 
in this country, unless in individuals who have come from warm 
countries, where they had suffered frequent attacks of the disease. 
In chronic dysentery, patients are affected with severe fits of griping 
about the umbilicus, like colic, which are quickly followed by an 
irresistible desire to go to stool, when a great deal of flatus is dis- 
charged, along with an evacuation which is sometimes of a dirty 
brown feculent matter, sometimes even much darker in colour ; at 
others it is greenish or yellowish; and occasionally the stool looks 
yeasty, or resembles thin gruel; sometimes, according to Mr. Mar- 
shall, like rice-water, or water in which a small proportion of white 
clay had been diffused. Sometimes there is only a sense of weight 
in the abdomen, and acute pain is perceived, upon pressure, in the 
course of the colon, but more particularly in the situation of the caput 
caecum. After each paroxysm of pain, and subsequent stool, the 
patient enjoys a longer or a shorter interval of ease, unless he be scald- 
ed about the anus. The skin becomes parched, and the pulse quick- 
ened ; the appetite is impaired in some cases, while it remains good 
in others ; but the patient will be observed to be worse after a mode- 
rately full meal, and occasionally there is nausea. Thirst is a pretty 
constant companion. The tongue presents various appearances, 
sometimes loaded, the fur being of a yellow colour; at others it is 
loaded in the centre, and reddish at the tip ; sometimes rough, and 



DYSENTERY. 273 

often it has the appearance which has been already described in this 
work, red, raw-looking, and quite smooth as if glazed. After these 
symptoms have continued, from two or three to twelve or fourteen 
days, the stools are found to consist of whitish mucus, frequently 
mixed with undigested food, and are almost always passed with con- 
siderable straining: the paroxysms of tormina increase; borboryg- 
mus is troublesome; the patient loathes food more and more; nau- 
sea is more complained of, and bilious vomiting occasionally takes 
place ; thirst increases, as well as debility and emaciation ; hiccup is 
often very troublesome; and the pulse becomes quicker and quicker, 
gradually losing its strength, the skin looks sallow, and at last death 
takes place. In the latter stages, the abdomen sometimes becomes 
more tumid ; at others, it is flatter than usual. Occasionally acute 
peritonitis cuts oil' the patient, from the escape of the contents of 
the bowels into the abdomen through an ulcerated opening 

tSppearancea on dissection, ivith pathological remarks. — In this 
country dysentery is rarely fatal, unless it attacks individuals who 
have Buffered severely from the same complaint in India. Neverthe- 
less, my museum contains sufficient proof that it is sometimes fatal, 
and that the post-mortem appearances closely resemble those which 
are found in tropical climates. I have known several fatal cases in 
Edinburgh, which ran their course in from nine to twenty days, and 
in which the colon, the rectum, and part of the ileum, were in a state 
of complete mortification, the parts having the gangrenous fetor. 
In other instances, the colon and rectum, throughout their whole 
extent, were thickened and contracted; the mucous membrane being 
soft and spongy, and dark-coloured, looking more like a livid fungous 
excrescence than an ulcerated surface; the colour being retained 
even alter maceration. An opinion has been too prevalent, that 
dysentery is always connected with a vitiated state of the bile, or 
actual disease of the liver itself; but the writings of modern patholo- 
gists h ive dispelled such delusions. 

Sir Gi orge Ballingall, in proceeding to give an account of the ap- 
pearances found on dissection, in his excellent work on Fever, Dys- 
entery, ice , stales, that in a great proportion Of eases, these appear- 
and i consist of an inflammation of thai part of the intestinal tube 
tied below the valve of the colon, " without the smallest trace 
of disease in the structure of the liver." 

The following are the appearances described by Mr. Marshall, de- 
puty inspector general of hospitals, in his valuable work, entitled, 
tes on the Medical Topography," &c. &c. I have great satis- 
faction in quoting from this author, because I know his descriptions 
were drawn from nature when standing al the dissecting table, with 

the morbid pails before bun, and not copied from books. « I 'pon ex- 

amining the bod:-- of Europeans, who have died of dysentery, (says 
he.) tie- extent of Btructui ment discovered is often very 

•• Omentum.— This organ is sometimes found greatly diminished ; 
Frequently it is found much thickened, interspersed with nu- 

merotn teasels, turgid witft dark-coloured bl band easily torn. 

Sometimes u adheres with great firmness to the intestines, occa- 



2T4 DYSENTERY. 

sionally stopping np ulcers. Perhaps it adheres more frequently to 
the caecum than to any other portion of the intestinal tube. 

"Intestines. — The folds of the intestines are often found aggluti- 
nated together. Sometimes they adhere to the liver, and occasionally 
to the bladder. The colon appears studded or streaked with dark 
red or plum-coloured spots. Sometimes the contents of the intesti- 
nal tube are found in the cavity of the abdomen, having passed 
through a gangrenous orifice in the coats. When handled, the large 
intestines feel thick, heavy, and lumpy ; they are, likewise, in many 
instances, easily torn. 

" Upon removing the intestines from the body, and slitting them 
up through the whole extent, a great number of lumbrici are com- 
monly found; but as worms exist so generally in the intestines of 
Europeans, in this country, their appearance cannot be considered 
as connected with dysentery. The inner surface of the duodenum 
is found covered with a viscid, glairy, semi-fluid substance, which 
has sometimes a yellowish, sometimes a greenish colour. Towards 
the inferior half of the ileum, small quantities of fecal matter are 
occasionally found, having a bright yellow colour, and some degree 
of consistence. The contents of this intestine frequently resemble 
the healthy alvine evacuations of young children. The colour and 
consistence of the fecal contents of the ileum are suddenly changed 
immediately upon passing into the caecum. Nothing is ever found 
in the large intestines but a brownish offensive fluid, similar in ap- 
pearance to the watery dejections which mark the last stage of dys- 
entery. The intestines were never found to contain either scybalae 
or fecal accumulation. 

"The coats of the small intestines are generally healthy; some- 
times they are redder externally than natural ; this redness appears 
to originate from venous effusion rather than from an actively ex- 
cited state of the vascular system. 

" The mesocolon is frequently found much thickened, and contain- 
ing a great number of vessels gorged with blood. 

"The chief traces of disease are found in the large intestines. The 
villous coat of the caecum, colon, and rectum, when expanded, some- 
times appears dark red, and extremely turgid ; the turgescence is oc- 
casionally so great, as to resemble the tumid state of the inflamed 
conjunctiva during a violent degree of purulent ophthalmia. 

"Sometimes the villous coat appears, at a little distance, to be 
covered with a bluish puriform fluid, and thickly interspersed with 
dark grumous spots and patches. When more narrowly examined, 
the villous coat is found to owe the appearance of being covered 
with puriform matter to an extravasation of fluids into the substance 
of it, by which means it acquires a swollen and pulpy appearance. 
The dark red grumous patches are portions of the villous coat in a 
gangrenous stale. These spots are generally surrounded by a red 
circle, the areas of which are various ; frequently they are not more 
than about a third of an inch. Sometimes an individual slough may 
be compared to a tainted oyster. The mortified portion of the vil- 
lous coat that is situated within the red circle is easily removed from 
the muscular coat, which is commonly found apparently not changed 



DYSENTERY. 275 

from a state of health. In some instances, the central portion of the 
slough had disappeared, leaving an excavation in the villous coat, as 
if a portion of it had been cut out. Even in these cases the muscu- 
lar coat was commonly sound. The villous coat was generally un- 
attached at the margin of the excavation, and the finger could often 
be easily pushed under it from one depression to another. Some- 
times, however, the sloughing extended into the muscular coat, and 
even into the peritoneal coat, which was rendered evident externally 
by the mulberry-coloured,patches. The dark spots on the peritoneal 
coat are always much less extensive than the corresponding gangre- 
nous portions of the mucous membrane. While one part of the 
large intestines has lost its natural tenacity from gangrene, another 
has sometimes acquired an increased power of resistance, and when 
cut into, conveys a semi-cartilaginous feeling to the hand. Some- 
times large portions of the villous coat are found sphacelated with- 
out any intervening living parts. In these instances, it is extensively 
separated from the muscular coat, and is sometimes found loose in 
the cavity of the intestine.* The gangrenous shreds occasionally 
stretch across the diameter of the intestine, like a bow-string. The 
separated portions of the villous coat are torn by the slightest force. 
They resemble, in appearance, pieces of dirty lint, imbued with the 
ichorous discharge of a gangrenous ulcer. 

• sometimes small collections of purulent matter are found between 
the villous and the muscular coats. This is, however, not a frequent 
occurrence. 

" Occasionally dysentery leaves traces of disease in the large intes- 
tines of a different kind, namely, tubercular ulcerations. Ulcers of 
this character are not uufrequently found spread over portions of the 
villous coat, and, for the most part, in a remarkably distinct and 
uniform manner. That portion of the villous coat which intervenes 
between the ulcers, has in general a loose, pulpy appearance. Some- 
times it is turgid and reddish. Viewed at a little distance, the inner 
surface of the intestine appears to besprinkled with a soft, curdy-like 
These cream-coloured specks are of various sizes ; some- 
times they are not more than a line, at other times they are an inch 
m diameter. I Ipon examining a small speck, the wrfariisb substance 
is found to protrude a little beyond the surface of the intestine, and 
adhering, but not very firmly, to the villous coat. After removing 
this substance, a depression or incipient ulceration is exposed. The 
and margin of the indentation are generally dark red. The 
depression eventually increases, and becomes an ulcer, which is 
always encircled by a red portion of the villous coat. Sometimes 
the i noble the ill-conditioned sores, with prominent edges, 

which occasionally occur on the inside of the lips, particularly during 
•.ere course of mercury, in general, the base and edges of the 

• indumted, Unequal, and scabrous. When tin; transverse 

section is math', a gristly feeling i - communicated to tin- baud. The 
tubercular appearance of these ulcers is very remarkable. They 

form of Inflammation I A secretion ol 
■ lymph from the mucoo i membrane, and not a portion of the membrane 

r-Mii.TrWs OB tbil tobjeet will be made in the chapter on Cholera.) 



276 DYSENTERY. 

sometimes resemble warty elevations with excavated apices, in a 
state of ulceration. For the most part, ulcers of this kind are oblong ; 
in length, they extend from half an inch to an inch; the breadth is 
seldom above half the length. The longest diameter is always in a 
transverse direction to the cavity of the intestine. 

" Such are the more common traces of disease, found upon inspect- 
ing the bodies of individuals who have died of dysentery, more par- 
ticularly among Europeans. Death rarely, if ever, occurs among 
this class of people before a certain degree pf gangrene of the villous 
coat of the large intestines has taken place. 

"Abscesses and other morbid states of the liver are occasionally 
concomitants of dysentery. When traces of disease in the liver 
were discovered, on dissection, the circumstance is noted in the table 
of casualties. The nature of the structural changes of this organ has 
been already mentioned. Upon examining the bodies of Malays 
that have died from dysentery, traces of disease of a less active cha- 
racter are discovered. The mesentery and mesocolon are generally 
found massy and dark-coloured, from turbid blood-vessels, and the 
lymphatic giands greatly enlarged. The coats of the large intestines 
are thickened and firm; frequently the calibre of the intestine is 
greatly contracted. The villous coat is, in these cases, unequal, 
puckered, and covered with a gelatinous muco-purulent substance. 
Occasionally, however, instances occur where the inner surface of 
the colon is found sprinkled with grumous spots in a state of morti- 
fication, and sometimes the sloughing portions are extensive." 

Some years ago dysentery was very prevalent and fatal in Ireland, 
which afforded Dr. Cheyne and others the most extensive opportuni- 
ties of making post-mortem examinations. They had the best proof 
that the primary and chief seat of the disease was in the mucous 
membrane of the intestines; the liver was sound in a majority of 
cases, but often otherwise. In two instances abscesses were found, 
and in many others great sanguineous congestion. 

According to Dr. Cheyne, the intestines were variously affected ; 
in some cases they were prodigiously distended ; the small intestines 
measuring from seven to nine inches in circumference; in some, the 
coats were much injured without thickening; in others, considerably 
thickened as well as ulcerated. In some cases the inflammation of 
the mucous membrane was most extensive, extending from the sto- 
mach to the rectum; the inflammation being always greatest towards 
the large intestines, the rectum being, however, sometimes sound. 

The morbid appearances discovered in the intestines, in fatal cases 
of dysentery, in this country, are considerable thickening of the large 
intestines ; sometimes this thickening affects the whole colon and 
rectum; sometimes it is confined to the caput caecum and part of the 
ascending colon, at others it involves also the arch, and even extends 
farther. The peritoneal coat generally remains sound. The seat of 
the thickening is in the mucous coat and sub-mucous cellular tissue, 
which are infiltrated with blood, spongy, with a rough and ragged 
surface. The colour varies from a bright red to a dark brown. 

On other occasions the mucous surface is spongy, rough, and rag- 
ged, with deep ulcerations here and there; the ulcerations running 



DYSENTERY. 277 

principally in the course of the transverse bands of the colon. The 
colour is sometimes very little changed, and there is little or no in- 
filtration of blood into any of the tissues. 

I have likewise seen complete mortification and sloughing of die 
mucous membrane in two dissections. In these instances, there Vvere 
large detached portions of the membrane, the sloughing condition 
being sufficiently well marked by the colour and fetor. The rectum 
has been implicated in a variety of the cases that have fallen under 
my observation, but it escapes more frequently in this country than 
in warm climates. There are some specimens and drawings in my 
museum, from which this description has been taken. 

Causes. — Dysentery is a disease which attacks individuals of all 
ages, and all classes of society, although those are more liable to it 
who are most exposed to vicissitudes of climate, and who are badly 
fed and clothed. Irregular habits also predispose to this disease. In 
warm climates it is found that Europeans suffer more than natives. 
Upon inspecting Mr. Marshall's tables, it will be seen that the disease 
is fatal during every month in the year; therefore it must occur in 
all kinds of weather. It is more peculiarly a disease of tropical cli- 
mates ; although we often see it in other situations, yet it is neither 
so prevalent nor so fatal. It also seems to depend upon the same ex- 
citing causes of fever. Although diseased secretion of the bile may 
occasionally produce both diarrhoea and dysentery, yet these diseases 
ought not to be so invariably imputed to this cause. 

Treatment. — The method of treatment which is generally found 
necessary in this country, shall be first shortly stated; and then that 
which ought to be adopted in warm climates in the acute and chronic 
forms of the disease. 

1st. Treatment of dysentery as it occurs in this country. — The 
same plan is to be pursued as in severe cases of diarrhoea. The body 
is to be warmed m a hot Lath; and as we are anxious to get rid of any 
offensive matter that may be in the bowels, in the first instance, an 
onhce, or half an ounce, of castor oil is to be given, with twenty, 
thirty, or forty drops of the sedative solution of opium; but if the 
stomach be too irritable to bear the castor oil, calomel, with a small 
quantity of opium, is to he given in pills every second, third, or fourth 
hour, nil a feculent evacuation is procured, assisted by a large injec- 
tion of warm milk and water, or thin gruel ; or small doses of salts 

may be given by tin: mouth, and repeated at short intervals. It is 
Wrong to suppose, thai in all instances of dysentery in this country, 
there are hardened faeces lodged in the bowels; but as this is some- 
times ill'- case, and certainly more frequently than in warm climates, 
the plan above recommended Bhould in the fust instance hi- adopted. 
'I 'Ins points out tli.- necessity of a careful examination of tin- alvine 
nations, which has been already so much insisted upon in other 
diseases. 

If however, a patient has considerable griping and tenesmus, hot 

skm. .ind a quick pulse, although it may not be p irticularly strong, it 
will !>•• right io bleed I mo, especially if there be pain on pressure; and 
perhaps it will be safest to draw blood before the laxatives are ad- 
orinisti red. One good bleeding will m general suffice; if there he 

24 



278 DYSENTERY. 

much subsequent tendency of abdomen, leeches may be had recourse 
to. After the diseased action has been thus reduced, and the scyba- 
lous matter got rid of, we may have recourse to large opiates by in- 
jection. It appears to me that the reason why opiates are not at- 
tended with more success is, that they are exhibited in too small 
quantity, and that they do not proportion the dose, in any degree, to 
the violence of the symptoms. If we suspect the liver to be disor- 
dered, small doses of calomel or blue pill may be given, but there is 
no necessity for greatly affecting the mouth. [At this stage of the 
disease, the alterative astringents come in extremely well; as opium 
and sugar of lead, with calomel, or the combination of camphor water 
and the mineral acids. With this last preparation I have conquered 
more dysenteric affections than by all the other internal remedies 
collectively. If opiates are required in large doses, (as often happens,) 
they are best given in enemata with starch or flaxseed. If anodynes 
are given by the mouth, the solution of morphia and solid opium are 
preferable to laudanum.] 

Contra-irritation to the abdomen is to be had recourse to, and the 
best method of producing it, is by the frequent application of hot oil 
of turpentine ; [or of brandy and cloves as mentioned under the head 
of colic. A poultice of bran and flaxseed, applied over the whole 
abdomen, in the manner recommended by Broussais, may be also 
tried with advantage;] but should the disease be very severe, it 
would be advisable to apply a blister. The attendants should be 
particularly cautioned to watch the heat of the extremities, and to 
apply hot bottles when necessary. 

In the excellent clinical reports with which Drs. Stokes and Graves 
have lately favoured the profession, it is stated, that strychnine, in 
doses of one-twelfth of a grain, given in a pill twice a day, was 
found useful in the Meath hospital. They tried this remedy on the 
authority of a paper by Dr. Rummel, inserted in the June number 
(1825) of Hufeland's Journal. On some late occasions this remedy 
has been tried in my practice, and was found exceedingly beneficial, 
even in cases where there were most extensive ulcerations in the 
bowels. It succeeded after every other remedy had failed. I have 
also seen beneficial effects from the acetate of lead, given in two or 
three grain doses several times a day. The sulphate of copper has 
also been strongly recommended in such cases by Dr. Elliotson; I 
have given it a trial, and can speak rather favourably of the result. 

The sufferings of patients are often much aggravated by flatulent 
distension of the intestines, which may generally be relieved by tur- 
pentine, assafoetida, or tobacco injection. During convalescence, the 
greatest attention must be paid to diet, clothing, and exercise. 

2d. Treatment of the acute disease as it occurs in warm cli- 
mates. — The only difference which is to be kept in view between 
the treatment of the disease as it occurs in this country and in 
tropical climates, is, that the disease being in the latter more severe, 
requires more active practice. It is also necessary to impress on the 
minds of those who are destined to practise in warm countries, that 
cases are frequently fatal, although the symptoms are apparently 
mild. That such cases are frequent, any reader may satisfy himself 



DYSENTERY. 279 

by consulting the works written upon this subject; and it has led 
some to divide the disease into two varieties. For instance, Mr. An- 
nesley states that there are two varieties, the acute and erythematic. 
" The first," says he, "is acutely inflammatory, and if not checked 
by bold and decided practice, will very soon terminate fatally, or lay 
the foundation of that chronic stage of dysentery which disables so 
many men. The second is more obscnre, and consequently, more 
dangerous. There is dull, deep-seated pain in the bowels, sufficient 
to distress a patient, but not so severe as to excite alarm. There is 
no external pain, the pulse is not materially altered, neither is there 
any increased febrile action. This disease," continues he, "is con- 
fined to the mucous membrane of the colon, and consists of a less 
acute form of inflammation of this membrane. If not treated suc- 
cessfully, it runs at once into ulceration throughout the whole intes- 
tines." 

These extracts are taken from Mr. Annesley's octavo work, which, 
contains much valuable information. It appears to me, however, 
that the term erythematic is most unhappily chosen, at least in con- 
tradistinction to the first variety, as the inflammation in both cases 
may be said to be erythematic. 

Great prejudices have prevailed in India, and I fear still exist 
among the older practitioners, against the employment of general 
bleeding, both in fevers and dysentery ; and the action of calomel is 
too much trusted to in these diseases. Dr. Johnson and Sir George 
Ballingall were among the first who, by example and precept, 
endeavoured to root out this error, by an appeal to the morbid 
appearances which have been already described. In later times, we 
have received additional testimony of the advantage of general 
bleeding. Mr. Annesley, in detailing the treatment of the acute 
form, when it occurs in plethoric individuals, recommends general 
bleeding, and states, that much is to lie done in a few hours, and if 
it be not got under control in that time, the patient is either lost, or 
the basis of a broken constitution is laid. But in those who have 
been long in India, and, I suppose he means, who have shattered 
constitutions, he says leeches will answer better, because they 
* diminish anion without destroying power, and any quantity of 
blood in iv be taken by them." I cannot agree with this too sweep- 
ing statement ; for I am certain, by experiment and careful attention, 
that individuals will dear the loss of blood better, ounce for ounce, 
by general bleeding, than by leeching. The cause of this remarkable 
imstance cannot be determined, although it appears probable 
that it in ay in part be attributed to the long-continued unpleasant 
ition produced by the biting of the animals and to the fatigue 
of the operation; but I am satisfied of the fectj leeches are cer- 
tainly to be preferred, however, when the disease is of long standing; 
they operate beneficially in many eases, when general blood-letting 

would no doubt prove injurious. Two great advantages Whjch the 
lanrei p.i i leeehi-s, are, that we can stop the bleeding 

from a vein in a moment, and promptly alter the determination of 
blood. 

At page B78, of Mr. Annetley'l octavo work, the following p 



280 DYSENTERY. 

will be found — " Full doses of calomel, with such other purgatives as 
act upon the mucous glands are required here, and should be con- 
tinued without intermission till healthy action is produced." To 
those who have seen the morbid changes produced on the intestines, 
who know and are acquainted with the dreadful mortality which is 
caused by dysentery among Europeans, and who have seen indi- 
viduals reduced to premature old age sent to this country on the pen- 
sion list, will join me in stating, that much injury has been inflicted 
by the mercurial treatment too generally pursued by medical men in 
the East; and upon which the passage last quoted affords me an 
opportunity of commenting. At this moment, I have before me the 
detail of many cases, which have been corroborated by frequent 
communications with practitioners who have served in India, of the 
baneful effects of the practice which seems still to be inculcated by 
Mr. Annesley. 

It is the custom in India to give calomel in large and frequently 
repeated doses, which is followed by the daily exhibition of drastic 
purgatives, which are given, to use Mr. Annesley's words, "to act 
upon the mucous glands, and are to be continued without intermis- 
sion." Under this treatment, the proportion of deaths is sometimes 
so great as 20 per cent., and on some occasions, it has been known to 
be about 30 per cent. Thus, Sir George Ballingall has shown, that in 
his majesty's 59th regiment, during eight months of the year 1806, 
ninety-seven men were affected with dysentery, of which number 
twenty-eight died. In his majesty's 30th regiment, during seven 
months in 1S07, four hundred and ninety-one men were affected with 
dysentery, of whom eighty-five died. And in the Royals, during 
eight months in 180S, five hundred and forty-one men were affected 
with the disease, of whom ninety-eight died. I have also some de- 
tails of the result of the mercurial practice in India, in my possession, 
which show the enormous quantities of calomel exhibited in dysen- 
tery of late years, with the bad success of the practice. It is no un- 
common thing for an individual to take three hundred grains of pure 
calomel, before he dies under the digestion of it. One individual took 
the enormous quantity of five hundred and twenty-three grains; 
another, six hundred and ninety-five; a third, seven hundred and 
sixty ; and a fourth, nine hundred and seventy-four, which last is 
somewhat more than sixteen drachms! So far from curing inflam- 
mation and ulceration of the mucous membrane of the bowels, there 
is no plan more likely to produce these states; but it is doubtful 
whether the calomel or the continued use of drastic purgatives is 
most injurious. The generality of purgatives operate by producing 
irritation and increased secretion on the whole mucous surface, which 
ought to be carefully avoided. It appears that many practitioners 
act upon the principle of getting rid of the mucous discharge, as if it 
were lodged in the bowels, acting like a poison ; whereas it is to be 
regarded as the effect of increased action. Let it not be supposed 
that I object altogether to the use of calomel ; on the contrary, I be- 
lieve that, combined with opium, its occasional use is most advanta- 
geous. My observations are only intended to prevent our trusting 
entirely to its operation, and to guard against its abuse. I shall con- 



DYSENTERY. s8 | 

elude, by quoting the result of Dr. Cheyne's experience in the treat- 
ment of dysentery, with respect to mercury, stated in the Dublin 
Hospital Reports, and that of Mr. Twining in the General Hospital 
at Calcutta. " Mercury," says Dr. Cheyne, « could not be depended 
upon, and did not relieve in numerous instances when the mouth 
was affected, and sometimes seemed to increase the disease; and even 
when the symptoms distinctly pointed out a morbid organization of 
the liver, the result of this treatment was unsatisfactory." My own 
experience in this country, as well as within the tropics, enables me 
to confirm the above statement. 

Mr. Twining, to whose talents and industry medical science stands 
deeply indebted, recommends venesection and the application of 
leeches, to decidedly reduce and permanently keep down any fre- 
quency and hardness of the pulse. He perseveres in this practice as 
long as pyrexia exists, or pressure on the belly gives pain, or there is 
any blood in the stools. He gives a laxative, and then six grains of 
ipecacuanha powder, with four grains of pil. hydrarg. He rarely 
uses calomel. 

'• .Notwithstanding all that has been written," says Mr. Twining, 
"in praise of the general employment of large and repeated doses 
of calomel in the dysentery of India, whether that medicine be used 
to the extent of producing salivation or not, it will be easy to show, 
calomel is often not only useless, but in many cases of the dysentery 
of Bengal, it is exceedingly injurious. I speak without hesitation 
on this subject, from having too often seen the fallacy of trusting 
generally to the effects of calomel for the cure of severe acute dysen- 
tery, and having tried that medicine extensively, in every form of the 
disease."* 

Treatment of chronic dysentery. — It must always be recollected, 
that no case of dysentery is to be regarded as altogether hopeless. 
From the recoveries which I have seen made, and from the dissec- 
tions at which I have been present, of individuals who have been 
long afflicted with the disease, it may be stated as a fact, that the 
mocOOfl Barface heats and becomes restored, if not to its primitive 
healthy Btate, at least in such a degree as to preserve life for many 
years. It is ran,-, in chronic dysentery, that we shall be called upon 
to take blood from the arm, but the occasional application of leeches 
is in-ist serviceable, together with contra-irritation, gentle laxatives, 
an occasional opiate, and astringent medicines, such as catechu, and 
solution of sugar of lead, and sulphate of zinc. Great care must be 
taken of the bowels and the diel ; small quantities of light and digesti- 
ble food are to be allowed at each meal, and the patient should not 
Dfl permitted to eal oftener of any thing than once in five or six hours. 
I have been very successful in the treatment of chronic dysentery, 
by following this plan, together with an occasional warm bath, and 
long perse\ erance in the use of tartar-emetic ointment, as well as by 

the occasional employment of mntton suet boiled in milk, which is to 

be strained immediately after il is to be taken off the fire, Bugar is 

then to be added, with a little BptCC to make it palatable; about four 

• Vide i>i as •• of Bengal, by William Twining, Esq,, !'• W 



282 CHOLERA. 

ounces of this are to be taken once or twice a-day, mixed with rice,* 
if th ■■ patient's stomach will bear it. [Radical cures have been de- 
rived from a persistence in a diet of gum-water and. the farinaceous 
articles, conjoined with absolute rest.] 



CHOLERA. 



This term, together with its adjunct, " morbus" is employed, even 
in common language, to express that a person is affected with vomit- 
ing and purging. 

This disease presents itself to us in two forms: Is/. That which 
has been so long known in this climate, and which occurs so fre- 
quently in warm seasons, more particularly when fruit is plentiful, 
and which is called cholera morbus. 2d. That form which so long 
prevailed in the east, and has lately visited Europe, which has ob- 
tained the name of Jisiatic cholera. 

1st. Cholera morbus. — The disease usually presents the following 
phenomena. The first symptoms are, nausea and griping sensations, 
which, generally speaking, come on suddenly, and soon terminate in 
vomiting and purging. In very severe cases, the body, and particu- 
larly the extremities, become cold ; the breathing is anxious and 
hurried; the features shrink; the eyes become hollow, with an ex- 
pression of great anxiety in the countenance ; the pulse small and 
contracted, soon becoming so weak as scarcely to be felt at the wrist; 
the thirst excessive ; cold water is the beverage most preferred, which 
is no sooner swallowed than rejected. A cramp-like feel is com- 
plained of in the legs, and sometimes in the arms, as in the severer 
cases of diarrhoea and dysentery, and occasionally spasmodic con- 
tractions of the muscles of the abdomen take place. The discharge 
from the bowels, in this country, is generally watery, with very thin 
and offensive fasces. Occasionally the discharge looks like water in 
which meat had been soaked ; at other times, dark bilious matter is 
passed in the first stage of the disease, both upwards and downwards, 
and subsequently the watery discharge takes place. 

Sydenham, in treating of the symptoms of cholera, which pre- 
vailed in London, in the year 1669, states, that they "often destroy 
the patient in twenty-four hours."— (Swan's ed. p. 147.) The fol- 
lowing case of cholera proved fatal in Dublin in thirteen hours, for 
the history of which I am indebted to Mr. Marshall. 

"Private Dickie, 26th regiment, aged 19, was brought to the hos- 
pital on 13th August, 1S26, in a state of great exhaustion, labouring 
under violent vomiting and purging, with which he had been at- 
tacked about an hour previously. He is also affected with severe 
spasmodic action in the bowels, and cramps in the legs; the matter 
vomited is bitter, and has a dark-green colour— that passed by stool 
has a dirty gray appearance ; face and extremities of a livid hue, 

* This is an old remedy; it is mentioned by 'Sir John Pringle.— The patient 
should in general be kept ignorant of the nature of the preparation, for fear of excit- 
ing disgust. 



CHOLERA. 285 

cold and clammy; no pulse at the wrist; the action of the heart is 
very obscure; articulates with difficulty, and moans incessantly; he 
cannot protrude his tongue; eyelids half closed; appears on the 
point of expiring; and he died before the lapse of twelve hours from 
the time of his admission, notwithstanding the adoption of the most 
judicious practice. 

"The only probable cause ascertained is, the drinking a quantity 
of porter before going to bed last night, but not to intoxication." 

Causes.— The causes are similar to those which produce other 
bowel complaints; as cold feet, suppressed perspiration from sudden 
exposure to cold, cold drinks when the body is much heated from 
exercise, crude vegetables, fruits, constipation, &c. 

Cholera prevails in this country chiefly in the autumn months suc- 
ceeding to hot summers. In 1S0S, many very bad cases fell under 
my notice, and again in the autumn of 1825. 

Treatment. — An emetic, consisting of a teaspoonful of mustard, 
in a large tumbler of warm water, is often very serviceable when a 
suspicion is entertained of acrid matter in the stomach, whether it be 
vitiated bile, or indigestible food. Fomentations should be applied 
to the abdomen, and the extremities warmed. 

It is too much the practice to exhibit strong purgatives in such 
cases, with a view of assisting nature to expel quickly offending 
matter from the intestines; but I could never convince my mind of 
the propriety of such a proceeding, when the evacuations are already 
so numerous; on the contrary, it always appeared to me that opiates 
are indicated, and experience has convinced me of the necessity of 
this practice. Opium ought to be conjoined with calomel, in the 
proportion of two grains to three or four grains of opium for an adult.* 
These two powerful remedies conjoined are found to allay irritability 
of stomach better than any other means. The calomel may be of 
service in improving the secretions; particularly the secretion of bile, 
if it be disordered. But large and repeated opiates, by the rectum 
as well as by the mouth, are frequently necessary. Stimulants are 
always to be exhibited when the extremities are cold, when the 
countenance and pulse exhibit signs of exhaustion, and when there 
are rmich irritability of stomach and pain in the abdomen. In gene- 
ral, brandy, or some other form of ardent spirits, is required, 

[ It, however, the disease does not yield to this simple treatment, 
and especially, if there should be great pain in the bowels, cups or 
leeches should be applied, or a stimulating poultice of bran and tlax- 
seed moistened with spirits and put on hot. Occasionally the reac- 
tion is so considerable as to require bleeding from the arm: and it is 
not uncommon for dysenteric symptoms to ensue.] 

During recovery, care must be taken to restore the healthy action 
of the stomach and bowels, by gentle, unirritating aperients; perhaps 

a short alterative mi-reiirial COUrse, and slight bitters, may be of use. 
The stimulants should be withdrawn by degrees, and finally omitted 
as the case improves; and th<- stomach should not be oppressed too 

• fl bave seen the b m uracil smaller doses, viz.: a quarter of a grain 

imel sod the san t opium repeated every hair hour; or the calomel may be 

exhibited in small doeei in gOOHMler, without ojiiuiii.] 



284 [ASIATIC CHOLERA.] 

early with food. The most suitable diet on the subsidence of the 
vomiting, is gum-water, and the farinaceous articles. 

2d. Asiatic cholera. — This, the most formidable disease of modern 
times, has obtained several appellations, viz., cholera spasmodica, 
cholera asphyxia, &c. The term "Asiatic Cholera," is adopted in 
this work, until a proper pathological name can be given to the dis- 
ease : every one, even in common life, knows its signification, while 
the other appellations imply erroneous theoretical views of the nature 
and seat of the disease, the adjunct "Asphyxia" being quite as ap- 
propriate to pneumonia, bronchitis, or fever of any variety. In truth, 
it might be added to the name of any dangerous disease, as most 
people "die from want of breath." 

Nearly two hundred years ago, a Portuguese, named Mandelo, 
in describing the diseases at Goa, makes the following statement: 
— " The change of seasons from one extremity to another, is the 
cause of many diseases among the Portuguese, but the most com- 
mon are those which they call Mordexin* or Mordechin, (the Hin- 
dostanee name for cholera,) which kills immediately, — burning fevers 
and bloody fluxes, against which they have in a manner no remedy 
but bleeding."t 

Cholera appeared in India in the worst form in which it had been 
observed by any living individual, in August 1817; since which time 
it has attracted very great attention. It has also been observed in 
the islands situated in the Indian seas; more lately, many thousands 
of the inhabitants of Russia and Poland have fallen its victims, and 
it has since visited most parts of Europe and America, causing every- 
where the most frightful ravages, and sparing, comparatively, few of 
those it attacked. 

[Geographical sketch. — Previously to the year 1817, the cholera 
appeared most generally in the sporadic or endemic form. But about 
the middle of August of the above year, it assumed the character of 
an epidemic, and extended with rapidity over Hindostan. Since 
that epoch, it has traversed seas, oceans and continents. Its com- 
mencement was at Jessore, a town situated 70 or 80 miles east of 
Calcutta. A Hindoo was first taken with vomiting and purging, and 
expired in great agony, upon the second day. His death was attribu- 
ted to eating spoiled rice ; but the same day, seventeen individuals, 
presenting similar symptoms, likewise died. The dispase then in- 
creased so as to destroy one-tenth of the entire population. It should 
be stated, as some assert, that the cholera appeared as early as the 
month of May, in the districts of Behar and Dacca. 

In a few weeks, the epidemic extended to the capital of British 
India, having prevailed with violence at the intermediate towns. At 
Calcutta, it did not reach the height of its severity for nearly a month, 
and the natives were among the first victims. 

During four months it pervaded the provinces of northern and 

* This term has been corrupted into mort de chien, as Mr. Marshall informs me, 
by a pun made by Sonnerat. 

t Travels into India in 1639, by John Albert de Mandelo, published in London, in 
1662, with the voyages and travels of the ambassadors, &c. &c. 



[ASIATIC CHOLERA] 285 

eastern Bengal, and then took a westward direction, towards the con- 
fluence of the Ganges and Jumna, where its progress was stayed ; but 
it soon broke out with increased mortality in the rich and commercial 
town of Benares. This being the holy city of the Hindoos, doubtless 
suffered more from the crowd of worshippers often there assembled; 
for it is computed that 15,000 persons died in less than two months. 
The deaths in one single district of Hindostan proper, amounted to 
thirty thousand. 

The English army, under the command of the Marquis of Hast- 
ings suffered most severely. The several divisions were encamped 
upon the banks of the Sinde, and their condition is thus forcibly por- 
trayed by an eye witness:* "It was here the disease put forth all 
its strength, and assumed its most deadly and appalling form: the 
old and the young, the European and the native, fighting men and 
camp-followers were alike subject to its visits; and all equally sunk, 
in a few hours, under its most powerful grasp." Nearly nine thou- 
sand were cut o(f in one fatal week. 

The epidemic next ravaged the countries lying between the rivers 
Nerbuddah and Kistna; and in twelve months from its appearance 
at Calcutta, it traversed the greater part of Hindostan. 

There was no uniform order of progression ; for Bombay on the 
western, and Madras on the eastern coast, were invaded in August, 
1818; the difference of invasion being only two days. 

As it is not intended to detail very minutely its march from place 
to place, we shall merely ohserve that in 1819, the disease manifest- 
ed itself at Ceylon, and taking an eastern course, appeared at Malacca, 
Java, and other of the Oceanic islands; advancing then in a norther- 
ly direction, it entered the kingdom of Siam, and destroyed 40,000 
persons in the town of Bankok. In 1820, Cochin China and Ton- 
qnin were invaded, together with other parts of Eastern Asia. 

Its progress has been traced north and east of Hindostan: let us 
now follow its course northwest. Starting from Bombay, it crossed 
lb-' sea of Arabia, to the city of Muscat, one of the principal com- 
mercial pons ii| Arabia, Tins was in 1881. Here its mortality was 
truly frightful, for 6,000 died, many of whom were not sick above a 
few hours; and we are (old, "lha! the living did not trouble them- 
selves to hnry tin: dead ; hut sewing the bodies up in mats, turned 
them adnYl into the harbour. The chief port-towns along the Persian 
(lull (ell 'lie influence of the pestilence, particularly Bassora, where 
nearly a thousand died daily for fifteen days; while at Bagdad 
30,000 perish., I. 

In 1882, S rvia ami Turkey were afTected by the disease, together 
with other neighbouring countries; and the following year it ap- 
peared along the Asiatic coast of the Mediterranean, and at the same 
time took a retrograde trad, ami showed itself at a town bordering 

Upon the Caspian sea, and shortly after al Asiraeaii. 

During l.s_> 1-5-ii and 7, it revisited many of the countries already 

mentioned. 

can was attacked a second time in 1830, together with the 

[♦ Dr. Jaiii«-s J.imcsoi).] 



286 [ASIATIC CHOLERA.] 

adjoining provinces ; and during this and the succeeding year, the 
ravages of the cholera throughout Poland, Austria, Russia, and along 
the coast of the German Ocean, are well known. In October 1831, it 
prevailed at Hamburg; and about the latter end of the month, it ap- 
peared in England at Sunderland, on the river Ware. Advancing 
northerly, it entered Edinburgh, in Scotland, and prevailed there and 
in the neighbouring places with considerable mortality, in the early 
part of 1832. At the same time that the towns in the north were 
attacked, those in the south also suffered ; for London had become 
the seat of the disease in February; here, however, the number of 
deaths was very small in comparison to other places. About the last 
of March, the epidemic was raging at Cork and Dublin, in Ireland, 
but did not continue long either there or in Scotland. 

On the 26th of March, it was officially announced that the disease 
had reached Paris, although the supposition was that it had existed 
there for some time previously; however, from this date it spread 
rapidly. At first those living in the densely populated and filthy 
parts of the town were seized, and its earliest victims were those 
wretched and imprudent mendicants who infest the environs of all 
large cities; but eventually it made less distinction, and attacked 
many persons in higher ranks of life. Its mortality can be judged 
of, when it is stated that between ten and eleven thousand perished 
in less than a month. From Paris it pervaded the greater part of 
France. 

We shall now contemplate the progress of the cholera upon our 
own continent. 

In fifteen years from the irruption of the malady in the Delta of 
the Ganges, it spread over Asia, traversed Europe, and commenced 
the work of death upon the banks of the St. Lawrence, without any 
mitigation of severity. 

Quebec was first attacked on the 8th of June, 1S32. It broke out 
among the Canadian French, and emigrants, many of the latter 
having just arrived from Europe in utter indigence. The number 
of cases and of deaths increased alarmingly, and 2000 were eventu- 
ally destroyed. The height of its violence was attained as early as 
the seventh day; and it continued moreover to rage, with greater or 
less fatality, for three months. Montreal was affected two days sub- 
sequent to Quebec: being one hundred and eighty miles southwest 
of that city. 

Meanwhile the pestilence visited the towns and villages along the 
St. Lawrence, and many places both on the British and American 
shores of the lakes. 

It appeared at New York on the 24th of June; but the Board of 
Health did not commence to report cases until the 5th of July, when 
twenty-one were announced. There, as in other places, no com- 
munication could be detected between the original cases. New York, 
from this visitation, lost nearly three thousand inhabitants. From 
this city the cholera passed up the Hudson river, and on the 3d of 
July, showed itself at Albany. 

The towns immediate to the two cities remained unaffected, at that 
time, but have suffered more or less since. " From the apparent 



[ASIATIC CHOLERA.] 287 

progress of the disease from Asia into Europe, it was supposed to 
have been transmitted along the great routes, communicating from 
one country to another. In the instance of Quebec, this general fact 
meets a contradiction. The disease commencing at Quebec, ascend- 
ed the St. Lawrence, and passed along the lakes until it reached the 
Mississippi and Missouri. It did not follow the land route into 
the states."* 

In Philadelphia, the first well-marked instance of cholera occurred 
on the 5th of July. Four days after, a second case was announced, 
and from this date up to the 30th, there was a slight increase of 
cases. It raged with the greatest violence amongst the inmates of 
Arch-street Prison and the Philadelphia Almshouse, although cases 
were scattered all over the city. The maximum of cases and of 
deaths happened between the 6th and 10th of August, inclusive. 
During these four days, 722 cases, and 2S7 deaths were reported. By 
the 26th inst., the epidemic had nearly subsided. On that day, only 
seven new cases were announced. 

In Philadelphia, as in Cincinnati and in other places, the black 
population were more obnoxious to the epidemic than the whites; 
and it was more fatal among adults, likewise, than children — among 
men than among women. 

Dr. Jackson remarks, " during the prevalence of the epidemic" in 
Philadelphia " an augmentation of other diseases took place, with an 
increase of their mortality. The diseases which appeared to be thus 
influenced by the epidemic, were those congeneric in character to the 
cholera, such as inflammatory diseases generally, gastric and enteri- 
tic disorders, gastro-enteritic fevers, inflammation of the abdominal 
viscera." 

During the months of July and August, the cholera was prevalent 
in several sections of New Jersey and Delaware. 

About the first of October, after the disease had continued three 
months along the valley of the St. Lawrence, it suddenly broke out 
at Cincinnati. 

"Nearly simultaneously with the invasion of Cincinnati, Madison, 
at the distance of SO miles, Louisville 150 miles, and St. Louis 400 
miles below, were attacked ; and by the latter end of the month it 
broke out at New Orleans. "t 

Departing from the banks of the Ohio, it proceeded to the neigh- 
bouring states — to Tennessee, Illinois, Indiana, and Kentucky. 
Several of the towns of the first and last-mentioned states suffered 
very much, particularly Lexington, Maysville, Danville, and Shelby- 
villc. 

Subsequently, the epidemic diffused itself through the valley of the 
Mississippi, and raged with great severity among the slaves at the 
Miutli and west. 

During the Bame year the cholera appeared in its most appalling 
form :n Campeche in Spanish America. Here, in one month, 4000 

OUt of a population <»l twenty thousand, fell victims to the scourge. 
In one day 400 WON buried. Sueh was the dismay of the inhabit- 

[• Dr. Jackson on Malignant Cholera.] [t Dr. Drake] 



288 ASIATIC CHOLERA. 

ants that houses were closed, streets deserted, and the physicians 
fled or secluded themselves. Coffins and graves were denied to some 
of the most respectable inhabitants. They did not pretend to give 
burials individually to the dead. Bodies were heaped together, and 
conveyed to the water's edge, where they received a partial cover- 
ing of sand. The remains of several who attempted to fly into the 
country, were found partly eaten up by birds, or beasts of prey. 
"What is singular, we are told that the susceptibility of those exposed 
to the malady, was dependent upon, or modified by, the proportion 
of impure or negro blood which they contained. Instances occurred 
where all the domestics of large families were cut off, and not a white 
took the disease. 

The epidemic has since appeared in Cuba, and the Charib Islands, 
and has revisited, with different degrees of violence, various parts of 
the United States. The seaport towns, with few exceptions, have 
been comparatively free from it. Sporadic cases of the disease have 
continued to occur in various parts of this country; and in the month 
of September, 1S36, it assumed the epidemic form in Charleston, 
South Carolina, where it showed considerable malignity.] 



In the former editions of this work, I was necessitated to compile 
the article on cholera from what were considered the best sources, 
having never had an opportunity of investigating the disease myself. 
Since then, I have unfortunately had ample means of seeing the dis- 
ease, and investigating its nature and seat, having acted as physician 
to the Drummond-street cholera hospital, in Edinburgh;* into which 

* It was with much reluctance that I accepted the appointment, from a feeling that, 
having a large family, I had no right to place myself in such a dangerous position 
I likewise felt that my healih, which was then rather impaired, would break up under 
an increased demand made upon my time, already loo much occupied; and lastly, 
that my private practice must suffer considerable injury, as few people, when cholera 
■was almost universally believed to be contagious, would send for me, knowing that I 
might come to them loaded with the contagious virus from the hospital. With all 
these feelings against the undertaking, and the urgent entreaties of particular friends, 
and having, at ihe same lime, neither expectation of reward to myself if 1 survived, 
nor suitable provision to my family if I perished, I at last accepted ihe office ; having 
done so, 1 made every preparation, even by increasing my esiablishment of horses, 
to enable me to perform ihe duties lo the best of my ability. The disease lingered a 
long lime in Edinburgh and its vicinity. The Drummond-street hospital was in great 
favour with thesuffering poor; on an average, during iheeleven months thatcholera 
prevailed, I made seven visits daily, often ihe number amounted to ten. Every 
night, with few exceptions, I made a visit between the hours of twelve and two. 
During the epidemic, 1 remained in the hospital, going from room to room, thirty 
complete nighis — which was sometimes necessary, from the young medical gentle- 
men being worn out, and also from the drunkenness that too often prevailed among 
the nurses. With few exceptions, each b >dy was carefully examined after death, 
with a view of unravelling the mysteries of this dreadful disease, and ascertaining its 
true pathological character, and, for the most part, these examinations were con- 
ducted with my own hands. Two hundred and eighty bodies were opened, and we 
were generally occupied two hours with each. Twice was I seriously injured with 
punctures; and on one of these occasions, my life was in jeopardy, from the inflam- 
mation spreading along the absorbents, accompanied by erysipelas of the whole arm 
and side of the body. Had I expected any honour or reward for my services, how 
grievously disappointed must I have been! The epidemic having at length termi- 
nated, there was no offer to remunerate me even for the expense incurred in purchas- 
ing and keeping an additional pair of carriage horses; there was no letter of thanks, 



ASIATIC CHOLERA. 289 

establishment there were received 461 patients, of which number 
291 died ; of these, 2S0 were examined most minutely, to ascertain 
the cause of death. 

Phenomena. — The disease consists of three stages. The first 
stage may be called premonitory ; the second, the stage of collapse ; 
the third, that of consecutive fever. 

The 1st stage is characterized by symptoms of indigestion, flatu- 
lent disturbance in the abdomen, precordial weight or oppression, 
slight nausea, acidity, griping pains, diarrhoea,* vertigo, some degree 
of headache, or tinnitus. These symptoms, even when accompanied 
by spasms, are too often either disregarded or concealed, till the 
second stage is far advanced. It is most unfortunate, that this 
reluctance to confess the early part of the indisposition should so 
frequently exist in all classes of society, but particularly among the 
poor, because few of the more severe maladies to which flesh is heir 
are so remediable as cholera in the first stage, and not one more 
hopeless after the lapse of a few short hours. 

It is stated by the Russian physicians, that at Orenberg, Moscow, 
and other places, scarcely a person escaped during the season when 
cholera prevailed, without some disorder of the stomach and bowels 
— indicated by iiausea, vomiting, and oppression at proecordia, indi- 
gestion, pain in the belly, and looseness of bowels. Many instances 
of disorder of the stomach and bowels prevailed during the epidemic 
season, and for some weeks before there was a well-marked case of 
cholera in Edinburgh. 

2d Stage. — The duration of the premonitory or first stage is 
various ; sometimes the unpleasant symptoms suddenly cease, and 
the patients recover quickly; but this happy issue is comparatively 
rare, when proper remedies are not used; and, in some few cases, 
from the peculiarity of constitution of the patient, remedies seem to 
have little etrect in arresting the progress of the disease, even when 
applied in this early stage. The stools, which were at first feculent 
and bilious, now become characteristic of the true Asiatic cholera. 
They have the appearance of very thin gruel, or rice-water; some- 
time (hey are watery, limpid, with small flakes of curdy-looking 

till the circumstance wa mentioned loonc of the members of the board of health, who 
went i.) the office, and desired the secretary "tu write a letter of thanks to Dr. Mack- 
intosh, and thai he conld scarcely make it loo strong!!" Knowing the hrregnlar and 
shabby manner in which it was got up, I put no value upon this document, and this 
only reward I Boon aflei wards, two vacancies for physicians took place in the 
Royal Infirmary of Edinburgh. I will confess I was most anxious to obtain one of 
lintments, but fell reluctant to become a candidate, nil a memorial was pre- 
i by almost ah the students, attending the Royal Infirmary, re- 
ing nit', for their sakes, to oiler my services. The Influential managers of the 
infirmary had been members ol the board of health; they all knew, and acknow- 
privately that they knew of my great exertions, doi only in attending 
the nek, bni in Investigating tbe oatuse ami seal "i <'"■ 'ii eaaei and In ha\ ing mainly 
s in organizing an efficiem tblishment. Km when the day of elec- 

tion arrived, I i •• er ; for w hich I tand Indebted (o the honourable medi- 

cal in .! I le me for tins disappointment, I had. i»\- calculation, sus- 

tained ■ lo a of two hundred pounds by the falling oil < . t my priva This 

' I lake this opportuj • li publicity. 

[• la the United E i day prior 

to an attack, but this preu doi uniform; for in some of tne worst < 

with, the bowels, up lo the moment ot the disease, were not u ian ed.] 
25 



290 ASIATIC CHOLERA. 

matter intermixed ; at other times, they present an appearance of 
water in which fresh beef had macerated. The usual feculent smell 
has vanished, instead of which the stools have a peculiar odour, 
which struck me to resemble that produced by macerating fish in 
water; a similar odour is generally observed from the surface of the 
body. More rarely, the stools look like the lees of port-wine; and 
it was remarked, that almost none recovered who passed " port-wine 
stools;" I recollect at present one recovery only in which there was 
this appearance — it was the case of Field, who was saved by saline 
injection into the circulation. The desire to go to stool is irresistible 
and instantaneous; tenesmus is great in some cases, sometimes pre- 
ceded or accompanied by a sense of heat or griping. The stools are 
generally very copious — sometimes, however, scanty ; often accom- 
panied by loud discharges of flatus from the bowels. Along with 
the bowel-complaint, there are burning heat in the region of the 
stomach, and vomiting of large quantities of a similar fluid from the 
stomach. The abdomen feels doughy. The thirst is intense, and 
there exists an urgent desire to drink cold water. The mind, for the 
most part, remains comparatively entire, but the vertigo and tinnitus 
increase. Cramps are general attendants — sometimes confined to 
the fingers and toes; at other times they affect the muscles of the 
extremities, and often those of the trunk of the body, more par- 
ticularly of the abdomen. The urine is generally suppressed early 
in the disease. The voice is whispering, the person being unable to 
speak in any other tone. The respiration, although weak, is often 
nearly natural in other respects, even at times when the pulse is 
scarcely perceptible at the wrist; occasionally, however, the breath- 
ing is hurried and oppressed, sometimes laborious. The pulse be- 
comes weak and rapid early in the disease, even when the action 
of the heart is comparatively strong and tumultuous; but frequently 
both the pulse and action of the heart are feeble. As the disease 
goes on, both become more and more weak; the pulse is only now 
and then felt, like a " flutter," and often ceases to be perceptible at 
the wrist for some hours before death. The tongue is cold and 
shrunk. It is quite painful to a bystander to watch the restlessness 
and impatience of the sufferers, who are constantly in a state of 
jactitation, more particularly when restrained, and when heat is 
applied. Indeed, they seem to have a horror at, and to suffer pain 
from, warm applications. The temperature of the body, but more 
particularly of the extremities, diminishes early in the disease, and 
goes on sinking. It is often impossible to raise the temperature of 
the body during life, but the moment death takes place, and for two 
or three hours afterwards, the body becomes warm — even the icy 
coldness of the extremities gives place to a genial warmth. The 
colour of the hands and feet becomes changed, more particularly the 
nails assume a blue appearance ; the face often is similarly affected ; 
occasionally the whole surface presents a blue colour, and, conse- 
quently, the second stage has sometimes been termed "the blue 
stage ;" but it is an error to suppose that the blueness is invariable, 
or that it is an attendant only on the worst forms of the complaint — 
the patient who had this appearance more strongly marked than any 



ASIATIC CHOLERA. 291 

other was the one who made the most rapid and the most complete 
recovery. Blood drawn from an artery or vein during this stage, 
flows with difficulty, is of a dark colour, does not coagulate or 
separate any serum. It remains in a semi-fluid state, and has the 
appearance which the ancients called * dissolved blood." The sur- 
face of the body is covered, for the most part, with a cold exuda- 
tion, the features and eyeballs shrink, and death closes the scene — 
sometimes very unexpectedly, at others the body seems to have been 
long dead, while the functions of the brain are still going on and 
comparatively entire. 

Sometimes the prostration of strength is extreme ; but it is my 
belief, that muscular debility is no part of the disease, till far ad- 
vanced iri the second, or collapsed stage. I have been surprised at 
the efforts made by patients when they were thought to be near 
death. Several patients ran to the hospital after seizure, and one 
walked from Bonnington Bridge, near Newhaven, to Drummond- 
street, a distance of two and a half miles at least; he was as blue as 
indigo, and his pulse was so weak, before starting, that it could 
scarcely be felt. The appearance of muscular debility is occasioned 
by the vertigo, which renders the gait unsteady and totiering, as well 
as by the dread of motion producing cramps. 

Many exceptions might be made to this account of the symptoms 
in these two stages. Sometimes no premonitory symptoms can be 
tr iced. I know of one case, where the person appeared to have 
died under the effects of the first attack of cramps; he was known 
to have laboured under slight bowel-complaint for several days, but 
he did not confine himself, and was lying without any complaint on 
a sofa : he was dressed, and engaged in reading. A noise was 
heard, and he was soon after found on the floor on his face, dead, 
with the book clenched in his hand, and his muscles rigid. — I have 
■een several cases where the urine was not entirely suppressed, and 
Others in which the Btoolfl were feculent and bilious up to the. moment 
of death. But those oases are to be regarded as exceptions to the 
role, which they do not contravene. The symptoms, in thin disease, 
as in all others, must Buffer modifications from peculiarity of consti- 
tution) previous condition of health, and habits of the patient affected. 

The symptoms which present the most unerring characteristics of 
Asiatic cholera, are diarrhoea, and other symptoms of disordered 
stomach and bowels, in the first 01 premonitory stage. 1 believe 
previous diarrhoea may be discovered in at least four out of six 
. and probably exists in all, if the history of each were perfect 
Thus, in the city of Albany, I'. S., diarrhoea occurred in 888 out of 
: in the remaining 64, it could not be ascertained whether 
tln> Bymptom bad or had not existed, in ihe stage of collapse, there 
are the whispering voice, great restlessness, characteristic discharge 
■pwards and downwards, cramps, suppression of urine, excessive 
tin rvt , weak, faltering pulse, week respiration, coldness of the ex- 
tremities, shriveled hands and feet, bedewed with a cold exudation. 
The general bliieness, when it exists, is also quite peculiar to cholera. 
li is remarkable bow quickly an extremely collapsed state of die 
features takes place. The blood-vessels, on such parts of the body 



292 ASIATIC CHOLERA. 

as the temples, where they are comparatively superficial and easily 
seen, are observed to be full of blood of a very dark colour ; even 
the serpentine branches of the temporal artery can be traced in this 
manner, and the motion of the blood is very slow. 

3d Stage. — A large proportion of patients died in the 2d stage ; 
there were few immediate recoveries from collapse, without under- 
going the danger and miseries of a consecutive fever, which is now 
to be described. I shall never forget the joy expressed by all who 
were watching the first case of cholera in which death did not take 
place in the stage of collapse. This feeling was increased as the 
watery diarrhoea, vomiting, and cramps diminished, and at last 
ceased, and as reaction became more evident and permanent. Nor 
shall I attempt to describe the subsequent disappointment, as bad 
symptoms arose one after another, to convince us that the patient, 
although he had made an escape from one set of dangers, was still 
surrounded by another, which experience speedily proved to us 
was extremely formidable. 

The symptoms that denoted an escape from the horrors of the 
second stage, were, diminution in the number and quantity of the 
evacuations, both from the bowels and stomach; cessation of rest- 
lessness, thirst, and cramps; increase of the temperature of the body, 
and strength of the pulse; an expression of animation in the counte- 
nance, and a disposition to sleep. Sometimes the stools lost the 
characteristic watery appearance, and became feculent; but this 
change was generally gradual. Sometimes the secretion of urine 
took place early after the reaction was established, but this favour- 
able circumstance rarely occurred so soon. In some cases, after 
every thing appeared to be going on well, the vomiting and purging 
suddenly returned, the pulse became weak and quick, and the patient 
rapidly died. 

The phenomena of the third stage presented every appearance of 
fever; sometimes of that form denominated in this country "typhus," 
and in several cases a similitude was easily traced to the last stage 
of yellow fever. In fact, the general opinion that was, and still is 
maintained, that cholera is nothing but a fever, with violent irrita- 
bility of stomach and bowels, suppression of the secretions of bile 
and urine, with a cold stage, appeared to derive support from the 
resemblance to the phenomena of intermittent fever. But it will 
soon be in my power to show how erroneous this opinion really is, 
when the pathology of cholera falls to be considered. 

After the complete development of reaction, patients for a time 
appear to be doing very well, not teased with violent tenesmus and 
vomiting, nor disturbed with intense thirst and violent cramps. The 
restlessness has ceased, and they seem to be enjoying tranquillity. 
But this state is generally to be regarded as a calm which is soon to 
be followed by a storm. The subsequent symptoms vary much in 
different cases, depending on the previous state of health and habits 
of the patient, and his peculiarities of constitution, as well as on the 
phenomena of the previous stage, and the treatment pursued. 

These symptoms were, lethargy or coma, which were frequent ; 
delirium; convulsions; paralysis; rigidity of the flexor muscles of 



ASIATIC CHOLERA. 293 

the extremities; distressing nausea; bilious vomiting, and thirst; 
dyspnoea, or hurried respiration; cough, expectoration ; palpitation 
and irregular action of the heart, and more or less heat of skin ; 
bilious diarrhoea ; port-wine stools; tenesmus; and pain or tender- 
ness, increased on pressure, in some part of the abdomen. Of all 
these symptoms, convulsions were the most rare. The others ex- 
isted variously combined and modified. 

Causes of cholera. — The undivided opinion of medical men, who 
saw the disease in India, is, that in the east it is not contagious. 
After the appearance of cholera in Russia and Poland, however, a 
belief became prevalent that the disease had been modified by cli- 
mate, and the habits of the people in Europe; that it had more re- 
semblance to a fever, and was highly contagious. There were few 
medical men who were not influenced by this specious statement ; 
and I confess that my mind was at one time so strongly impressed 
with the belief in the contagious nature of the disease, that for the 
first five or six weeks after its appearance in Edinburgh, when I 
retired to bed at night, I scarcely expected to find myself alive in the 
morning. But my fears were at last dispelled, and my opinion is, 
that, if it be contagious, it is not so in any very great degree. The 
following are the grounds on which this opinion is formed. — It was 
Intimated to me, by authority, that, as the disease was so contagious, 
every possible precaution must be taken to prevent its extension, 
and that few bodies could be allowed to be opened, as the contagion 
was more virulent and searching after than before death. But from 
the moment my mind was made up to accept the appointment, I 
resolved that fear should not be allowed either to interfere with my 
attendance on the sick, or to hinder my investigations after death. 
Accordingly, in attending the first case of cholera in the hospital, I 
remained in the ward all night, and became so much exhausted, that 
I fell fast asleep in the bed next the dying person, and slept for 
above an hour, at a time when my animal spirits were low, and my 
physical Btrength diminished by the fatigues of the previous day. 
[uently, I hive more than once accidentally fallen asleep on a 
bed "ii which some unfortunate had died, and in a ward in which 
there were several dying persons at the time. None of the house 
lurgeone, the number being between twenty and thirty, who were 
Seldom out of the wards, had the disease; although their bodies must 
hare been ready to receive the contagion, if fatigue of body, anxiety 
of mind, and want of sleep, ever predisposed any person to take a 
Two male nurses had cholera. One was a sober man. and 
although he had the warning diarrhoea, he neglected himself, but had 
the d htly. The other was a complete, tippler ; he had a 

slight bowel-complaint, which he concealed, and by way of curing 
it, obtained leave to go home to see his family ; he got drunk, and 
vai brought to the hospital with cholera, but never became col- 
lapeed. Several female nurses were also attacked; hut that is no 
wonder-, for, independent of the fatigue they underwent, they were 
drunkards, and had characters in other respects j and were actually 
in the habit of drinking the spin's and wine served out to their 
patients. Two of these characters, after much fatigue and a hard 

*25 



£94 [ASIATIC CHOLERA.] 

course of drinking, went to bed one night quite drunk ; they were 
both speedily seized with cholera — one died. But there is no proof 
of the influence of contagion in these cases. In truth, no case has 
ever been advanced in proof of the contagious nature of cholera 
that cannot be explained on other and more satisfactory principles. 
Is it because four children, with father and mother, in one family, 
have had cholera, and because communication can be proved be- 
tween them and an infected house, by means of a bundle of dirty 
clothes, or a web of linen, or actual personal contact, that we are 
rashly to attribute the whole to contagion? The same story may, 
perhaps, be told in a different way. The father is a dissipated good- 
for-nothing man, who spends almost all his wages on whisky, he 
deprives his family of the means of procuring suitable nourishment; 
the poor mother has pawned her last blanket, to purchase a few 
potatoes for her starving children, who have all had loose bowels for 
several days or weeks. The explanation is easy to show the strong 
predisposing cause— insufficient clothing, deficiency of food, &c. 
What answer can be made to this fact, that I have seen several 
mothers suckle their children when they themselves were dying of 
cholera, and in one instance I found an infant suckling its dead 
mother's breast — and yet not one of them had a symptom of cholera, 
at least for months afterwards ? The wife of the first person attacked 
with cholera in Edinburgh, was found "dead drunk" lying with 
her face on the breast of her dead husband, whom she had robbed 
of his stimulants; yet she escaped the disease! — 1 shall drop this 
subject, after submitting the following statement to my readers. In 
the Drummond-street cholera hospital there were 280 bodies ex- 
amined. Two, and sometimes three hours, were spent in examining 
each body. From the economical arrangement of the board of 
health, and the difficulty of procuring a proper apartment, the dead- 
room, where these examinations were conducted, was a miserable 
place about eight feet square; generally six or eight persons were 
present, sometimes more ; and in an inner apartment, about ten feet 
square, there sometimes lay six dead bodies. Not one of those who 
frequented this den of death, and who had their hands imbrued in 
the secretions of the dead for six hours out of the twenty-four, were 
affected with cholera, although their hands were irritated and punc- 
tured daily ! 

[It may be added, that when the cholera was raging in Moscow, 
it is said that 40,000 persons fled to the country ; but there was no 
instance of the disease having been conveyed by them to the dis- 
tricts that received them. 

Dr. Jackson remarks, that "the routes or lines of communication 
leading from the river St. Lawrence to the United States do not ap- 
pear to have been the means of conducting it into our territories, for 
it commenced in New York without a possibility of tracing its im- 
mediate origin." 

Further, contagious diseases generally advance slowly and pro- 
gressively; but we have seen, both in this country and abroad, that 
towns, hundreds of miles distant from each other, were affected 
almost at the same time. 



[ASIATIC CHOLERA] 295 

In Philadelphia, the first cases reported were in separate and dis- 
tinct parts of the city, and had no intercourse with each other. In 
New York, and some of the western towns, similar facts were no- 
ticed; facts which are directly opposed to the acknowledged pheno- 
mena of contagion. 

If the contagious theory be correct, we cannot understand how it 
is that the epidemic has often skipped from one point to another 
at a distance, leaving the intermediate places unaffected: as illustra- 
tions, we refer to the immunity of villages between Canada and Cin- 
cinnati to the healthiness of the towns between New York and 
Albany, &.c, at the very time that the disease existed in those places 
themselves. Instances of the kind were numerous in this country ; 
but we shall close these remarks by the following striking facts, 
(which are sufficiently conclusive,) from the last edition of Dr. Eber- 
le's Practice of Physic. 

"In the report of the extraordinary committee of health at Mos- 
cow, it is stated 'that at the opening of bodies of persons who had 
died of cholera, to the minute inspection of which four or five hours 
a day, for nearly a month, were devoted, neither those who attended 
at the operations, nor any of the assisting physicians, nor any attend- 
ants, caught the infection, although, with the exception of the first 
day, scarcely any precautions were used.' In the cholera hospital 
of this city, (Cincinnati,) in which, during a period of nearly five 
weeks, there were constantly from fifteen to twenty cholera patients, 
not a single case of the disease occurred among the attending physi- 
cians, nurses and other attendants, although some of these remained 
in the wards day and night, during the whole period, and frequently- 
slept on beds where cholera patients had lain and died. Dr. Walker, 
speaking of the disease as it prevailed at Moscow, says, that • per- 
sons had put on the clothes of patients who were very ill, or had 
died of cholera — had lain in their beds, and even along side of dead 
bodies — had bathed in the same water where very bad cholera pa- 
tients had been bathed just before, and that, notwithstanding, not 
one ol these individuate was attacked with the disease.'"] 

It cannot be denied that some mysterious influence was operating 
at the period cholera prevailed, by whatever name it may be called 
— that it selected its own victims — exercised its poisonous qualities 
in oil-' <li>mct, town, or hamlet, more than in another— changed the 
•Dene of its ravages luddenly and capriciously, and made its progress 
from place to place, by strange detours, avoiding many populous 
Situations, in the direct tract of human intercourse. 

This influence showed its visible effects on the stomach and bow- 
'•ls, by embarrassing the functions of the various organs connected 
with the digestive; functions. Mr. Dick, the professor of veterinary 
medicine in Edinburgh, published a paper in the "Veterinarian" 
fol April, L833, wherein it is shown that cholera was by no means 
uncommon among < i> >nif^r i<-. annuals, particularly horses and cows, 
during the epidemic season in Edinburgh. They had diarrhoaa and 
rigid cramps J tin- blood was viscid and dark; the discharge from the 
bowels | that from the human subject. Several annuals 



£96 ASIATIC CHOLERA. 

died suddenly, and the appearance, on dissection, resembled those in 
the human subject, particularly in the stomach and bowels. 

Were any persons more prone to contract cholera than others? 
This is an important question, and it is rare that a point in medical 
investigation can be so satisfactorily answered. All who had any 
important visceral disease, or tendency to bowel-complaint from 
slight causes, and drunkards, were the persons generally attacked. 
It is no doubt certain, that in each locality where cholera prevailed, 
some instances may be quoted to the contrary, but these are very 
few indeed, and are to be regarded as exceptions to the general rule. 
Nothing could be more unsatisfactory than the accounts we received 
of the previous health and habits of patients; very frequently we 
found them to be quite the opposite of what had been stated ; but 
when we opened the bodies, in the careful and minute manner in 
which the dissections were conducted, we had the best evidence that 
few subjects were even tolerably sound. 

Persons advanced in age, had, in the epidemic that I saw, a bad 
chance of recovery. Females seemed to be more liable to the dis- 
ease than males. Almost every woman we opened, under a certain 
age, had the catamenia; and we found a great number of diseases, 
of various kinds, of the uterus, ovaries, tubes, and broad ligaments. 

Morbid appearances observed in cholera. — These might be di- 
vided into those appearances connected, and those unconnected, with 
cholera. It appears to be not only proper, but necessary, to sepa- 
rate these info two classes of morbid appearances, when we are col- 
lecting evidence to enable us to draw legitimate conclusions re- 
garding the nature and seat of any disease. This may not be 
easy, or even possible, in every case of cholera; but in general it is 
a task readily achieved by any one who has been so much em- 
ployed as I have been, for nearly thirty years, in making patho- 
logical researches. A distinction must also be made between the 
appearances found in persons who died in the stage of collapse, and 
those in the consecutive fever, or third stage. 

Among the appearances we met with unconnected with cholera, 
may be mentioned, tumours, and old abscesses in the brain ; ancient 
thickenings, and osseous productions of the membranes; diseases of 
the heart, lungs, and blood-vessels; morbid lesions of the liver, gall- 
bladder, and ducts of the spleen, kidneys, and uterus, of the stomach 
and bowels. Diseases of these organs we saw in almost every case, 
either singly or in various combinations. Although this distinction 
is necessary when employed in searching for the true nature and seat 
of cholera, yet all the morbid appearances must be again combined 
in considering the dreadful mortality of the disease. In doing so now 
it appears to me that the influence, whatever it may be, whether 
electrical, dietetical, atmospherical or terrestrial, selects diseased sub- 
jects. 

No other conclusion can be drawn from the facts I have seen. On 
the other hand, some of these appearances, such as ulcerations of the 
bowels, diseases of the kidneys, extensive diseases of the lungs and 
heart, and more particularly extensive diseases in the inner surface 
of the arteries, must be placed in pathological connection with other 



ASIATIC CHOLERA. 297 

circumstances, to enable us to account for the varieties of the disease, 
the occurrence of certain symptoms, their obstinacy, the effects of 
remedial agents, as well as the causes of death. 

The morbid appearances peculiar to cholera observed in those 
persons who died in the collapsed stage. — The blood attracted our 
attention in the first dissection, and it had the same appearances to 
the last. It was dark-coloured, and had lost much of its fluidity; 
this was expected, from the accounts that had previously reached us 
from other countries. But we were astonished to find that it was 
contained in the arteries and veins, in the most minute capillary, as 
well as in the larger vessels ; that it had the same dark colour in both 
sets of vessels, to some of them containing a small quantity, others 
being enormously distended.* The capillaries and large veins on the 
surface of the body contained as much blood after death as during 
life. On opening a vein in the dead body, the blood flowed almost 
as readily as it had done during life in the same person. The surface 
therefore retained the same dark appearance as it presented during 
life, and the muscles were of a dark red colour. In the act of death, or 
immediately afterwards, in all other diseases, the blood leaves the ca- 
pillaries, recedes from the surface, and collects in the heart and large 
veins near it ; the arterial system is generally quite empty, but occa- 
sionally a little blood is found in the aorta. Here are at once observed 
three remarkable facts; 1st. An alteration in the appearance and con- 
sistence of the vital fluid; 2d. A change in its distribution; 3d. Blood 
can be drawn from a vein almost as readily after death as during life; 
and the important circumstance may be noticed, that there was an 
appearance everywhere of abundance of blood. Every incision that 
was made even in parts not depending, occasioned a flow of blood, 
so as often to be troublesome, by impeding our examinations. Some 
thought the blood oily. 

In the head. — Great vascularity was observed on the surface of 
(be brain and in the membranes; — not only were the capillaries in- 
jected, but the trunks of both arteries and veins were filled with blood 
—the Vertebrate, carotids, and circle of Willis, as well as the vena 
li,and the longitudinal and lateral BinUSes. In the longitudinal 

and lateral sinuse, however, the Mood was not always in a semi-fluid 
state, but often coagulated ; and sometimes then; was a fibrous clot 
extending through the course of the sinuses of the brain, into the 
jugular veins. Tins appearance of fibrine was observed also in those 
who died in the consecutive feyer. Oh the lateral surfaces of the 
hemispheres of the brain, we frequently observed an extensive ec- 
ehymotic patch; sometimes there were several patches of this kind. 
This appearance was produced by an effusion <>f hloody serum be- 
n the arachnoid and pia mater. The injection on the surface of 

the brain WM more florid than that in any other part of the body. 
The BCChymOtiC ipOt OCCUpied in some rases only ahoiit an inch and 

I m length j m others it was very extensive, involving the whole 
of the hemispheres, and occasionally extending down between them. 

* I a the dimenafona of eon f the abdominal v< 

1 ' i above the bifurcation, •; LOiht "i an Inch. 

< ' >'hs. 

Bn inch. 



298 ASIATIC CHOLERA. 

The vessels of the pia mater, the velnm interpositum, the plexus 
choroides, and the lining membrane of the ventricles, were injected. 
The surface of the fourth ventricle, in general so white, was seen 
vascular, occasionally slightly strained with blood. The ventricles, 
whenever they were examined with a view of ascertaining ihe point, 
were found to contain a considerable, sometimes a large quantity of 
serum. Sections of the brain displayed the cortical snbsiance much 
darker than usual, and the brain generally exceedingly vascular. As 
soon as a section was made, there immediately appeared numerous 
large drops of blood, in size and number much greater than are ob- 
served in other diseases, even in active inflammation of the brain. In 
above one hundred and fifty cases, the spinal marrow and its mem- 
branes were minutely examined. In all, there was a very consider- 
able quantity of serum, the membranes highly injected, the rachidian 
veins gorged with dark-coloured blood, and the substance of the 
spinal marrow, in a few cases, appeared a little softer in texture than 
natural. In a large number of subjects, there were ossific depositions, 
in the form of scales, seen on the arachnoid surface ; occasionally they 
were very numerous and large. 

The general practice was, to place the subject on the face as soon 
as death occurred, with a view of preventing engorgement of the 
spinal marrow and brain, from a depending position. 

In the thorax. — The lungs were found gorged with dark viscid, 
oily-looking blood ; they were heavier than natural, in some instances 
weighing 3lb. 9 oz/* Pleura minutely injected; in those who died 
rapidly, both the pleura and pericardium had a dry appearance ; in 
other cases the pleura had an unctuous feel, also the serous surface of 
the pericardium and heart. Ecchymotic spots, of the form and size 
of petechias, were frequently seen on the pleura costalis and pnlmo- 
nalis, extending in many instances a line or two into the substance of 
the lungs. Occasionally, in those who died in this stage, there were 
seen one, or perhaps two, small portions of the lung indurated, and 
stained of a dark red colour, presenting all the characteristics of "pul- 
monary apoplexy ;" this appearance, however, was more frequent 
in those who died in the consecutive fever. The bronchial membrane 
was injected, the tubes occasionally gorged with mucus, of various 
degrees of tenacity and tinges of colour. 

The surface of the heart and large vessels was very vascular, pre- 
senting many ecchymotic spots, more particularly on the acute mar- 
gin of the right ventricle and aorta. In many instances, these were 
found to extend deep into the subjacent tissue. On making sections, 
to display the cavities of the heart, the left ventricle was almost 
invariably found in the state at hypertrophy, with diminution of the 
cavity, and generally empty. In the right auricle and ventricle, 
there was found a fibrinous clot, sometimes white, like coagulable 
lymph, at others, stained with blood, consisting partly of lymph and. 
coagulated blood of a dark colour. When a mass of lymph was 
found in the right auricle and ventricle, it invariably extended into 
the pulmonary artery, and in many cases could be traced into the 

* This subject was a male. The smallest weight in a male aged 33, tall and well 
proportioned, was 1 lb. 1 oz.; and in a female aged 38, it was the same. 



ASIATIC CHOLERA. £99 

smallest ramifications; and sometimes the pulmonary veins had a 
similar plug. On several occasions, the auriculo-ventricular opening 
was closed by the plug, prolongations from which were found inter- 
lacing between the columnar carnese and cordse tending. 

In the inner surface of the aorta, and in a few cases in the pul- 
monary artery, also, there was seen a distinct false membrane, com- 
pletely covering the inner membrane, and extending into the vessels 
that are given off from it ; this membrane did not always seem to be 
of recent date, but in many of the dissections it was observed in an 
incipient state. It was most completely formed near the heart; and 
on some occasions it was seen below the arch of the aorta, in the act 
of forming, presenting an appearance like tenacious mucilage, con- 
tinuous with the portion already organized. Occasionally it was 
tinged of a dark, sometimes of a bright red colour; but generally it 
was white, and easily separated from the proper lining membrane, 
even with the handle of the scalpel. In the few cases in which it 
was found in the pulmonary artery, it was thinner, and not so com- 
pletely organized. In the aorta, we frequently traced it to the bifur- 
cation of the iliacs; sometimes half-way from the heart, perfectly 
organized, the rest being in a gelatinous state. When separated, the 
proper shining smooth character of the inner membrane was seen 
beyond all doubt, except at parts whore there were artheromatous 
depositions, which were sometimes confined to the false membrane, 
at others extended into the proper coats of the artery. 

We carefully removed the contents of the thorax, not only with a 
view of submitting them to minute examination, but also to investi- 
gate into the condition of certain nerves and ganglions. I shall now 
show the stale in which we found the pneumogastrics, phrenics, 
splanchnics, and semilunar ganglia. The dissection of the neck 
sliowed minute injection of the large vessels, both sets containing 
dark-coloured blood, more particularly the veins, which were often 
not only full but distended. 

The pneuraoga8tfic nerve was frequently seen stained of a dark 
red colour, through its whole course in the neck and thorax. Some- 
time there was merely vascularity on its surface, till it crossed over 
the subclavian artery, where, in many cases, it was enlarged, so as 
to reseml e a ganglion. This enlargement was always tinged of a 
blight purple colour, and exited on the right side only. But the 
nerve was frequently similarly tinged at this point through its 
whole substance, when there was no enlargement On tracing 
these nerves onward in their course, they frequently presented a red 
appearance. 

The phrenics,as they passed over the pericardium, were observed 
to partake of the general injection; and When the pericardium pre- 
sented a half-dried appearance, these nerves were similarly a fleeted. 

In a great many cases, we carefully traced the splanchnics on both 
rides of the Bpine, to the semilunar ganglia. In this part of the 
Ihorax, there were minute injection oj the vessels, and ecchymotio 
specks, like petechias. Thi w< re implicated in the injection 

on their surface, but in two subjects only was there any discolora- 
tion or olh< i in ii u of disease in tlie substance. In one or two cases, 



SG0 ASIATIC CHOLERA. 

it was thought the ganglia were somewhat changed from the natural 
colour, but we discovered our error, having had, at that period, 
several opportunities of examining these ganglia in persons who 
died of other diseases, when a similar appearance was seen. 

•Abdominal organs. — In the stomach, in two or three cases, we 
found a considerable quantity of undigested food that had been eaten 
a few hours before the attack, and, on one occasion, a number of 
small stones, pieces of slate and tiles. In some cases, there was 
considerable injection of the peritoneal surface of the viscera, but 
this was by no means frequent. The stomach was in general con- 
tracted, sometimes remarkably so, and several times divided by con- 
traction in the centre, into two cavities. The intestines contained 
more or less of a matter similar to that vomited during life. Unless 
the patient lingered long in the second stage, no appearance of bile 
was seen in the bowels. The mucous membrane of the stomach 
was occasionally, but not always, vascular; sometimes quite white, 
but almost always much softer than natural, and in many cases 
thickened and quite pulpy, so as to be removed with the slightest 
touch of the handle of the scalpel. The mucous membrane of the 
intestines was in general more vascular than that of the stomach, 
sometimes more minutely injected than if size and vermilion had 
been thrown into the vessels. Occasionally there was ecchymosis, 
and frequently softening of the mucous membrane, sometimes ulcer- 
ation, particularly in the ileum and colon. The mucous follicles 
were generally enlarged, and Peyer's patches, so rarely seen in adult 
age, were seldom wanting; they were large, elevated, soft, and 
spongy, and sometimes slightly ulcerated.* In many cases, we 
found the colon, and sometimes the ileum, thickened, the mucous 
membrane soft, dark-coloured and disorganized, as in some of the 
worst forms of dysentery. 

The liver was frequently diseased, and the disease not of recent 
date. Occasionally this organ was very vascular, and we rarely 
missed seeing sufficient quantity of bile in the pori. In two instances 
only were there such appearances of engorgement as are described 
by the India writers. 

The gall-bladder was in every instance filled; sometimes distended 
with dark-coloured and somewhat viscid bile, the organ itself being 
very vascular, and in many cases containing gall-stones. In no 
instance, save one, did we discover any impediment in the passage of 
bile through the ducts into the duodenum. In that solitary instance, 
a spherical-shaped calculus obstructed the passage. 

The kidneys were generally diseased. The disorganization de- 
scribed by Dr. Bright, was very frequently met with. The vessels 
of these organs were almost uniformly highly injected — a puriform 
fluid was always found in the papillae. 

[* M. Buillaud remarks, that " this hypertrophy, this species of erection of the fol- 
licles of the mucous membrane of the digestive 'tube, prevails sometimes distinct, at 
others confluent; and imitates, to a certain extent, the variolous eruption in the first 
stage. The same gentleman found the mucous membrane, in several instances, to be 
in a state of putridity, which lesion appeared more frequently in the small than in the 
large intestine. Andral and Louis also found gangrenous appearances in the 
mucous membrane of the small intestines in severe cases.] 



[ASIATIC CHOLERA.] 301 

The bladder was always contracted, so as to be as small and dense 
as a virgin-uterus. 

The following appearances tvere found in the bodies of those 
who died in the third stage. — Marks of inflammatory action in the 
membranes, and more rarely in the substance of the brain. In al- 
most every case the vessels ramifying in the membranes were injected; 
there were traces of ecchymotic patches and turbid effusion between 
the arachnoid and pia mater, as well as in the ventricles. In many 
cases we found the fibrinous plug, formerly mentioned, in the sinuses 
adhering to t he sides of the vessels. In several cases, inflammatory 
disorganization was seen in the substance of the brain; sometimes 
the white ramollissement, or liquefaction of the septum lucidum and 
walls of the ventricles, and in two or three cases the red ramollis- 
sement and destruction of considerable portions of (he brain. It 
must be confessed, however, that in a few cases the brain was to all 
appearance sound. The traces of bronchitis, pneumonia, pleuritis, 
and pericarditis, were frequently observed too decidedly marked to 
be mistaken ; such are to be expected from the injected ecchymosed 
condition of these parts in the previous stage. We frequently found 
the fibrinous plug in the right side of the heart, extending into the 
pulmonary artery; it was generally more dense than in the second 
stage. I never saw so many examples of inflammation of the tissue 
of the lungs, as in the dissection of persons who died in the third 
stage of cholera. In the abdomen, traces of inflammation of the 
peritoneum were also discovered. The mucous membrane of the 
stomach, bowels, lungs, and kidneys, presented similar appearances 
to those noticed in the second stage. Feculent or bilious matter was 
always met with in the intestinal tube, and frequently urine in the 
bladder ; sometimes the latter organ was much distended. The 
coals of the gall-bladder were still highly injected; the organ itself, 
instead of bile, now contained a serous fluid, having a yellowish or 
Dish tinge. If the person lived some days in the thud stage, the 
of the blood and its distribution more and more resembled the 
appearances seen after death from other diseases, 

[For the following cases, illustrating the pathological appearances 
nred in Philadelphia, I am indebted to my friend Dr. R. K. 
Porter. 

1 ft. — Peritoneal coat of the intestines and of the other viscera 
dryish externally; tin; intestines presented a very reddened appear- 
ance. The stomach had in it one or more gills of whitish fluid: 
several highly reddened patches were scattered over the villous coat. 
The glands of Payer enlarged in certain parts of the small intestine; 
its inner coal injected, softer than natural, and had upon it an ad- 
herent whitish matter, Which Dr. Horner remarked was coagulable 
lymph; the upper portion contained an abundance of cream-like 

limd, in which there was a large quantity of the lymph ; towards the 
lower part, the. fluid was of a serous nature. The mucous mem- 
brane, ai various points, umn reddened, softened, and the coagulable 
lymph could be easily washed or scraped oil". 

Can %(L— Bowels externally dry, and much injected. The sto- 
ma'! i contained one pi ut of t Inn yellowish fluid; mucous coat softened, 
N 



302 [ASIATIC CHOLERA.] 

and easily raised; about the pyloric region it was injected. Duo- 
denum externally injected with a bluish-red colour ; its contents were 
yellowish; below this the intestine was nearly filled with a whey- 
like fluid; inner membrane sanguineous, and had much fibrinous 
matter attached to it, flakes of which were most beautifully seen 
when a portion of the bowel was put in water. In the colon, the 
same fluid and matter were observed. 

Case 3d. — Dryness of the intestines, which were externally of 
a red-bluish colour. The stomach had in it a pink-coloured fluid ; 
the mucous coat was of a mottled or whitish marbled appearance ; 
duodenum contained an abundance of a similar fluid as the above, 
with flakes of lymph floating in it, the latter in some places so abun- 
dant as to appear for inches as a deciduous membrane. There was 
much whey-like or rice-water fluid in the ileum. Inflammatory 
points seen throughout the digestive tube. 

The anatomical researches made by Dr. Horner, during the con- 
tinuance of cholera at Philadelphia, in 1832, have very much tended 
to elucidate its pathology. He has not only confirmed some of the 
observations of others, and attached to them their deserving import- 
ance, but he has also ascertained some new morbid anatomical cha- 
racters of a highly interesting nature. By him the cholera is regarded 
as the consequence of an increased flow of blood to, or throughout 
the mucous membrane of the stomach and bowels; followed by sub- 
sequent inflammation and sloughing of the same, or of its super- 
ficial venous layer ;* after speaking of the extent and minuteness of 
the gastro-enteritic venous system, he adds, that the morbid derange- 
ments of the vascular and follicular structure of the mucous mem- 
brane, endowed with vital actions the most important to life, consti- 
tute the essential characters of cholera. 

He demonstrated that the small intestines especially, were often 
lined with coagulable lymph, the membranous nature of which 
was proved by maceration in alcohol, and by the process of drying.t 
This substance has been considered as mucous by most persons, 
whilst a few regarded it in its true light, but did not lay that stress 
upon it of which it was deserving : otherwise the therapeutic mea- 
sures handed down to us, would have been far less numerous and 
contradictory. 

In several cases he met with a vesicular eruption in the bowels, 
which he believes to be independent of, or distinct from, an enlarge- 
ment, of the mucous follicles or glands'; its form is spherical, and 
about an hundredth of an inch in diameter. In a recent state it is 
supposed the vesicles contain a fluid ; but in a dried state they are 
empty, and transparent. They appear in groups, isolated or in thick 
patches ; in the upper portion of the intestines, they are far more 
numerous than they are towards the ileum and colon. Upon this 
point he thus speaks : " I observed, besides the vesicles, which were 

* [The mueous coat of the digestive tube is made up almost entirely of veins, the- 
meshes or intertexture of which are arranged into deep and superficial layers.— 
Horner.'] 

t [Both in India and England the analysis of cholera fluid detected the. presence 
of coagulable lymph.] 



ASIATIC CHOLERA. S03 

as distinct from each other as marbles on the same ground, that some 
were clustered. In the stomach, I found a single bunch, resembling 
a bunch of grapes standing on its base; and in the ileum and colon, 
I found clusters resembling bunches of grapes reposing on their sides. 
Such clusters had for their nidus, and for connecting them together, 
a deposit of coagulable lymph." 

In three cases he also discovered that the epidermis and venous 
lining of the intestinal canal wffre destroyed, more especially of the 
stomach and colon. After a most successful injection of certain parts 
of the bowels, he states, " in regard to the veins, when the parts were 
dried, they opened on the internal surface of the stomach and bowel, 
as if excoriation had left them bare; the superficial venous layer of 
the colon was entirely detached, except in a few places; and there it 
seemed like the skin of a locust just ready to fall off, it being so loose 
that the injecting matter had not passed into it.*] 

Pathological considerations respecting Asiatic cholera. — After 
having reflected on the morbid appearances seen in the first twenty 
cases that occurred, and having compared these with the phenomena 
of the disease in its different stages, and contrasted them with the 
symptoms, terminations, and morbid appearances observed in other 
complaints, I began to suspect the correctness of the opinion promul- 
gated by the medical men in India, at different times since 1S17. 
Every hour's experience strengthened a belief, that their views were 
Unfounded and erroneous. The general belief is, that cholera (how- 
ever produced and propagated,) affords the best example of a disease 
consisting of a loss of balance in the circulation, and consequent ac- 
cumulation of blood in internal organs; — that death is occasioned by 
nation of the blood, and the impossibility of creating reaction. 
This view of the nature of the disease seemed to receive support 
from the following circumstances: 

Is/. The difficulty in procuring a flow of blood on opening a vein 
or artery; the slow motion of the blood, its dark appearance, and its 
imperfect coagulation. These arc circumstances frequently observed 
in intermittent and other fevi rs. 

of venesection, when employed early in the dtsi ase, 
in India, made practitioners conclude, that the practice of venesection 
operate I by unloading tin: internal organs of the accumulation of 
blood that oppressed their action, and restored tin: balance of the 
circulation. 

;-/. Tii-: phenomena in tin: third stage appeared to support the 
Bt ween cholera and those forms of fever preceded by a cold 

I following facts appear to mc to disprove these views in a 

ictory manner, 
1*7. Th<- absence of rigors. I have not seen any practitioner who 

i ih it he had evei observed this phenomena in cholera. Tin: 
nee of rigors struck my mind <nrl y iii the epidemic, as a remark- 

■ rcumstance, distinguishing cholera from all other diseases, but 

• [The reader ii refem rl and xvii.of ibe Araef. Journal of Medics 

ten be will Bod in detail the views of Dr. Hornet in relation lo'tha 
paiholof . 



304 ASIATIC CHOLERA. 

more particularly those characterized by a decided loss of balance of 
the circulation, and accumulation of blood in some internal organ or 
organs. 

2d. Every individual remedy, which in the other forms of disease 
connected with loss of balance of the circulation occasions remark- 
able mitigation of suffering, produces discomfort, and even pain, in 
cholera. 

Thus, in cholera, hot applications and drinks are dreaded, which 
in the cold stage of other diseases are urgently and importunately 
demanded. In the cold stage of intermittent, for example, there is a 
demand for warm drinks and hot applications; in cholera for cold. 

3d. The full state of the blood-vessels on the surface of the body 
in cholera, after death as well as during life, contrasted with their 
empty condition, particularly after death, in all other diseases. 

What persons were most frequently attacked? — The answer to 
this query has been already given, and is now a matter of history. 
The weakly, particularly those who are liable to complaints in the 
stomach and bowels, and who are subject to diarrhoea. The desti- 
tute, who can command neither proper food nor raiment. And 
above all, the dissipated, particularly those who are addicted to the 
habitual use of ardent spirits. 

The condition of the blood is very remarkable, and has attracted 
the attention of the most superficial inquirer. Even without the 
assistance of chemical analysis, it is quite evident that the blood is 
thick, tenacious, dark in colour and has an oily appearance, flows 
with difficulty from vein or artery, and coagulates imperfectly. But 
by the analysis of different chemists, it is established that the serous 
part of the blood, the salts and the albumen which the serum holds 
in solution, are found deficient to a great extent. These experiments 
differ in minute results, but the broad fact is as above stated. 

This thick blood, after finding its way into the arterial capillaries, 
cannot easily escape, owing to its viscidity. This is one cause of the 
slow motion of the blood. In many parts, these small vessels give 
way, and ecchymosis is the consequence. This appearance has been 
seen in every organ of the body. 

It is not unreasonable to suppose, that the blood becomes viscid 
by the abstraction of the serum, and that this is effected by the co- 
pious watery discharge from the stomach and bowels. If this view 
be correct, it will enable us to apply the doctrines, by which Boer- 
haave attempted ineffectually to explain the pathology of inflamma- 
tion, to Cholera Asiatica. 

In reviewing the long list of morbid appearances already described, 
it becomes a matter of the first importance to determine accurately, 
if any of these lesions are peculiar to cholera. If so, can they, by a 
fair process of reasoning, be connected with the symptoms in the re- 
lation of cause and effect? 

It has been already admitted, that a large proportion of the morbid 
appearances must have existed before the attack of cholera. They 
are brought forward as decided proofs of the previous diseased con- 
dition of the system of those attacked, acting as powerful predispos- 



ASIATIC CHOLERA. 305 

ing causes of cholera, and also to assist in accounting for the fatality 
of the disease. 

I must further state my opinion, that a number of the morbid ap- 
pearances considered peculiar to cholera, are undoubtedly occasioned 
by the diseased condition of the blood, and cannot be considered as 
causes of cholera. But they are strictly connected as causes of death 
in the collapsed or blue stage, and of the phenomena of the third 
stage. They prove satisfactorily why so few made rapid recoveries, 
and why so many had necessarily to undergo the miseries and dan- 
gers of the consecutive fever. 

Treatment of Asiatic cholera. — No better evidence can be offered 
of the ignorance of the profession generally as to the nature and seat 
of any disease, than the number and variety of remedies that have 
been confidently recommended for its cure. This was never better 
exemplified than in the disease now under consideration. 

The following long catalogue was made out at the time cholera 
prevailed, but it is not even pretended that all the remedies are enu- 
merated. 

I esection; cupping; dry cupping; arteriotomy. — Emetics of 
mustard, ipecacuanha, antimony, and sulphate of copper. — Calomel; 
colocynth, singly and combined; castor oil; croton oil; jalap; opium; 
Calomel and opium; llnid mercury, mercurial frictions; opium com- 
bined with antimony; opiate confection; colchicum; cajeput oil ; pep- 
permint oil; capsicum; charcoal; camphor variously combined; aether; 
mint tea; spt. retheris nitrici ; magnesia; milk; milk and magnesia 
combined; lime water; alkalies; spt. amnion, aromat.; Dover's pow- 
ox. bismuth. — Various balsams. — Acetate of lead; nitrous acid; 
soda water; cold water ad libitum} water prohibited; effervescing 
draughts; strychnia; various rubefacients in the shape of frictions, 
sinapisms, embrocations.— Various coutra-irritants — as blisters, anti- 
mony ointment, moxas, actual cautery, bastinadoing the feet! Cut- 
tiny; the throat! Suffocating under a feather-bed! Injections of 
oxygen gas into the bowels! The application of heat in the shape 
mi bath, vapour bath, fomentations; dry heat; the application 
1 1 nism. — Injections of beef lea, starch and opium, tur- 
pentine, chamomile tea, hoi water, cold 'water, strong solution of 
i fusa, tobacco, port-wine, alcohol, sulphate of copper, acetate 
. be. Stephen's drug ; saline injection into the veins. 

The above list would be humiliating to the whole profession, were it 
not remembered how mnch anxiety and excitement prevailed among 
cal men at the time; so much so, that several lost their reason, 
and many their lives on the occasion. Many of these remedies are 
totally opposite in their nature and principles of action ; many of 
them were proposed upon erroneons principles, ami many moro 
upon no principles at all; hut by far the greater number were recom- 
mended on the prevailing notion, that cholera was a disease atlbrd- 
i cample of a loss of balance of the circulation, and 

pent accumulation Of blood in internal organs. The diarrhoea 

and vomiting v. I as efforts of nature to unload the cn- 

gorg . Hid therefore formed an important part of the .sana- 

tory pro 



306 ASIATIC CHOLERA. 

I have already attempted to show that this was a pathological 
error; and, if the views which have been given in these pages be 
correct, the practice must have been very prejudicial. I allude more 
particularly to the following remedies — bleeding, purgatives, and 
emetics. 

Another theory, that cholera depended on deficiency of the biliary 
secretion, requiring large and frequently repeated doses of mercury, 
has, I believe, been also prejudicial. 

With respect to the advantages that may reasonably be expected 
from abstracting blood, I believe that venesection may be employed 
in the first or premonitory stage, when it acts by checking the diar- 
rhoea, and allaying the irritability of stomach. After collapse took 
place, bleeding in any form rarely proved serviceable, and was in- 
jurious in most instances in which it was employed within my obser- 
vation. But it is a remedy which ought to be kept in view, to mode- 
rate febrile movement, and to extinguish local inflammations in the 
third stage. 

Having made these brief general remarks, I shall now describe 
the treatment which experience at the bed-side, and morbid anatomi- 
cal investigations, have led me to adopt; postponing for the present 
the consideration of the practice of saline injection, which it is my 
intention to notice in a separate article. 

A patient should be treated according to the actual state in which 
he is found ; this circumstance, therefore, leads me to consider the 
treatment in the different stages of the disease. 

Treatment in the first stage of Cholera. — This it will be remem- 
bered, has been likewise termed the premonitory stage. If there be 
evidence of the stomach being loaded, vomiting may be induced by 
a copious draught of tepid water, chamomile tea, or mustard and 
water. [The mustard emetic is made by dissolving a teaspoonful 
of common salt in a tumbler of warm water, and mixing therewith 
a tablespoonful of finely powdered mustard. This is taken at a 
draught.] The stools should be examined: if they contain hard 
masses of feculent matter, a mild injection may be administered, or 
a small dose of castor oil exhibited. But should the stools be watery, 
copious, more particularly, should they have assumed the character- 
istic appearance, the diarrhoea should be immediately checked by a 
dose of laudanum, an opium pill, combined with a small quantity of 
calomel,* or a few grains of opium introduced into the rectum. A 

[* Calomel, in cholera, should be mainly given with a view to its alterative effects, 
for which purpose it is best combined with opium, in the proportion of two grains of 
the former to one of the latter, repeated every half hour or hour until the discharges 
are checked, and the stomach is tranquilized. Larger doses are sometimes allowa- 
ble, and even requisite. Dr. Porter informs me that a very malignant case was 
cured in the Philadelphia Almshouse Hospital in 1834, after all other means had 
failed, by the exhibition of a drachm of calomel, which was repeated in three hours; 
the stools then became tinged with bile, and convalescence soon followed. 

The western physicians, however, have used it most profusely, making it the ba- 
sis of ilieir practice ; and they assure us that it produced the happiest results even in 
highly malignant cases. The mode in which they administered it will appear to 
many both rash and dangerous : but it should be remembered, that the inordinate 
doses were mostly given in desperate cases, where other remedies had proved una- 
vailing. Thus, Dr. Corinth, of Indiana, who has had extensive experience in cholera, 
commences the treatment with an emetic, followed by fifty or one hundred grains of 



[ASIATIC CHOLERA.] 307 

warm bath should be used, and the patient afterwards put to bed. 
If the patient have been previously in good health, temperate in his 
habits, and the pulse strong, a vein may be opened, and a sufficient 
quantity of blood abstracted. It is in such circumstances that vene- 
section may be expected to be useful. 

[Venesection in the United Slates, has been confined to a com- 
paratively small number of physicians. Dr. Chapman observes that, 
when he is called at the commencement of an attack, unless there is 
extreme depression, he bleeds freely, and cups the epigastrium. Dr. 
Jackson considers venesection as but partially applicable to cases of 
cholera. " It should be restricted to those only where the constitu- 
tion is vigorous, and the patient has not been enfeebled by age, pre- 
vious disease, or dissipated living, and when the forces of the general 
circulation do not manifest a tendency to decay." He adds that, on 
the approach of collapse, it is a hazardous remedy. We are also in- 
formed by physicians, who have practised in the western states, and 
had ample opportunities of observation, that the results of general 
bleeding were not of a character to inspire confidence. Experience, 
in this country, has indeed fully proved, that venesection is inadmis- 
sible after the system has become collapsed from large and frequent 
serous discharges, and especially when these contain an abundant 
flocculent or fibrinous matter. Local bleeding by cups and leeches, 
is of great advantage; they should be applied to the epigastric and 
iliac regions, and are particularly demanded when venesection is 
equivocal.] 

I have known many individuals destroyed when in this critical 
state, apparently by taking a laxative, even a small quantity of 
calcined magnesia, or an emetic. Saline medicines should be pro- 
scribed during the continuation of a cholera epidemic, for I have seen 
several people sink rapidly into a fatal collapse under their operation, 
who had had no previous bowel-complaint, but felt slight oppression, 
which made them wish to unload their bowels. The patient should 
be carefully watched, so that the heat of the body may be kept up 
to the natural standard by proper applications — the discharge oppor- 
tunely restrained by the employment of opiates— and the pulse 
orted by the exhibition oi stimuli Digestion being in all such 
impeded, the lightest food only, such as arrow-root, should be 

allowed, and m small <|iiantny at a tune. It is in this Stage that 
■ us draughts of any liquid prove injurious. When patients 
. ■■ from the condition just described, a slight febrile movement, 

calomel every boar, mail the diarrbosa ceases : the quantity is then to be reduced to 
twenty iivi' grains every two hoars, until salivation ocean, which he assures us is 
ttwaj followed t>v a restoration of the healthy Becretions. In one hundred patients 
in u bom K | laced, be lost sol s tingle case ; and he farther declares that 

patten u took, before recovery, a quarter of a pi mini of calomel I 
Bat of all the the mercurial plan, I ok Is the warmest : b< 

and in those of severe character, 
he Increases the dose to an oun< | and one case la report- 

recovered after ba pound of calomel '• 

i 'here Mated i orloriiy. not for imitation. It is surprising 

what thi- bu undergo without annihilation ; and itscapabilt- 

narvelloua indeed.] 

• Hr BcrlS uncrUthBl r»rn n pounil »nd « half h»TO bten gl»on in 18 hour*.] 



308 ASIATIC CHOLERA. 

symptoms denoting cerebral irritation, or considerable bodily debility, 
frequently follow, either singly or combined, and must be treated 
accordingly. Confinement to the house, great quiet, and attention 
to the functions of the stomach and bowels, must be enjoined for 
some time, as relapses are frequent ; and I have known fatal collapse 
to take place suddenly in sevetal cases after one or two such warn- 
ings had been neglected. 

Treatment in the second stage of cholera. — Although I have 
known venesection employed advantageously, and strong purgatives 
used without producing death in this stage of the disease, I cannot 
state the fact too 'strongly, that they are dangerous remedies. In 
taking a retrospective view of the cases as recorded in the books of 
the Drummond-street Hospital, I cannot but condemn the practice 
which I myself had recourse to, but more particularly, that which 
relates to the exhibition of purgatives; and were I treating the dis- 
ease again, I would avoid exhibiting any remedy that would in the 
least degree tend to produce one additional alvine evacuation, or 
irritate the stomach. 

Rubefacients form another class, along with irritants, which can- 
not be too strongly condemned in the second stage. They were 
recommended upon the old view of producing a flow of blood to 
the surface, in order to relieve internal organs. Long before I knew 
the error of this theory, I had arrived at the conclusion, that they 
never do any good, while they irritate and annoy the sufferers. 
Much have I been pained to see moxas and the actual cautery 
applied. I never observed beneficial results in any case from these 
remedies, although the hot iron has been drawn along the spine on 
each side, from the occiput to the sacrum. Hand-rubbing would 
seem to be serviceable, by assisting the motion of the blood ; and it 
appeared to allay the severity of the pain occasioned by cramps. 
Although hot applications seemed to create uneasiness and im- 
patience, still I am convinced that warmth is necessary, when the 
temperature of the body is much reduced. Warmth appeared to 
mitigate the violence of cramps, if it did not prevent their recurrence. 
It appeared to me that dry heat was best. I therefore had tin cases 
constructed the length and breadth of the body, to contain the 
vapour of boiling water. Each tin case was open at both ends, 
was deposited in the centre of a loose straw bed, and covered with a 
folded blanket. It formed rather a hard bed, but there were few 
patients who could not endure it for two or three hours, and there 
was seldom occasion to keep them longer. After a number of ex- 
periments, I succeeded so well that I could heat a bed sufficiently in 
three minutes, and support the heat for any length of time, or reduce 
it at pleasure, by vapour from a boiler, which' communicated by 
pipes furnished with stop-cocks, with several beds in each receiving- 
ward. 

Cholera patients suffer from intense thirst, and their anguish al- 
ways appeared greatly increased if they were restricted as to the 
quantity of liquid. In the Drummond-street Hospital every method 
was tried, viz.: by restricting the quantity of liquid, by allowing a 
moderate quantity, or affording an unrestricted supply; and we came 



ASIATIC CHOLERA. 309 

to the conclusion that the last was the best method. [Broussais 
found nothing so good as ice in the treatment of cholera ; he further 
says, that in the cold stage he began with hot drinks, but soon 
abandoned them for ice itself. It is now adopted everywhere, the 
patient being directed to keep small pieces of it almost constantly in 
his mouth, during all stages of the disease. It reduces the irritability 
of the stomach, quenches thirst, and alleviates the general distress of 
the sick. 

The sickness of stomach is a most distressing symptom: when all 
the usual means of allaying it have been tried in vain, Dr. Eberle 
assures us that nothing is so effectual as camphor dissolved in sul- 
phuric ether.*] 

Stimulants are necessary when the pulse and action of the heart 
become feeble, but should be discontinued upon the occurrence of 
reaction. 

It has been already stated, that the discharge from the bowels 
should be checked as early as possible. For this purpose opium, in 
various shapes, has been used. Perhaps the best method is to give 
repeated small doses by the mouth, or to introduce an opiate sup- 
pository into the rectum. The acetate of lead and sulphate of cop- 
per have been used for this purpose, but not with good effect. I 
was induced to employ strychnia as an astringent, and began with 
doses of 1-1 2th of a grain ; we gradually increased the quantity to 
1 grain, repeated, according to circumstances, every hour, or second 
hour. We thought good effects were produced; and in one or two 
instances only, did spasmodic twitches or other unpleasant symptoms 
arise, although this powerful remedy was pushed to considerable 
extent. It appeared to act by not only restraining the discharge 
from the bowels, but by shortening the collapse, and rendering the 
reaction more permanent. I frequently wished that gentlemen who 
proposed new remedies, would look at the morbid appearances. If 
the mncOUS membrane of (he stomach were so soft and pulpy as to 
ifljly separated from the subjacent coat by a touch of the handle 
of a scalpel, surely irritating medicines are contra-indicated! If 
there were great irritation, inflammation, ulceration, and an appear- 
of sphacelation of the targe intestines, surely injections of port- 
wine, alcohol, salt dissolved m water, and more particularly, potassa 
improper. In truth, from indiscreet zeal, much mischief 
wis occasioned ; by doing i<><) much, the sufferings of many a patient 
were greatly increased, and odium was thus brought on the profes- 
sion. In the Driiuimond-strcet hospital, we fairly tried all the reme- 
recommended, but observed no advantage from a large majority 
of them. Thus, Stephen's saline solution, which, it was stated, had 
operated like magic elsewhere, was tried and laid aside. Tins medi- 

'. is ii ed for lb'' purpose of restoring the serum of the blood; 
but no on-- who has seen the mitCOtlS nieinhraiie of the stomach and 

bowels in cholera subjects, can have any faith in such a remedy, it 

n"t tend serviceable In anyone ease, and was injurious in 

mm;., hy Sidling vomiting and purging, The oxide of bismuth 
[♦ Appendix, Prescrip. 70.] 



S10 ASIATIC CHOLERA. 

and nitrous acid were prescribed according to the directions received; 
but we never could discover any advantage from their use, although 
they were less injurious than most of the other remedies. 

[For the cramps, frictions, saline pediluvia, the tourniquet, &c, are 
all in use, though sometimes they afford little relief. In the last 
case of cholera that came under my notice, and which was attended 
by the most distressing cramps I ever witnessed, I had tight stock- 
ings drawn on the legs, over which a bandage was tightly applied 
beginning at the toes; the relief was immediate, and with occasion- 
ally renewing the bandages still more firmly, the spasms were 
entirely subdued, and the patient recovered. I have not met with 
this plan in any of the works that have come under my notice; but 
whether it be new or not, I can confidently recommend it to the 
notice of the profession.] 

Treatment of the third stage of cholera. — It has been already 
stated, that as soon as the stage of collapse begins to give way to 
reaction, stimulants should be diminished, and ultimately omitted 
entirely. Looking at the vascular engorgement of the capillary 
vessels in every organ in the body, together with the ecchymotic 
spots, so frequently discovered on dissection, there is nothing very 
encouraging to support us in any plan of treatment. But we must 
recollect that recoveries do take place, and that there are no limits to 
the efforts of nature when she is in difficulties ; and that the chances 
of recovery are greatly increased, if we are acquainted with the 
morbid condition of vital organs, and know the kind of assistance 
that ought to be afforded. My impression is, that we do not trust 
to nature sufficiently in the early part of this stage ; that we have 
always been too anxious to increase the force of the circulation ; and 
in too great haste to produce feculent evacuations, and a copious 
flow of urine. By erring in this respect, irritability of stomach is 
created, and when this is once established it is very intractable. I 
know of no remedy which can restrain the violent bilious vomiting 
except extensive leeching, and irritating the surface of the abdomen. 
I have seen much benefit produced by venesection in this stage, as 
also from repeated applications of leeches to relieve the brain, lungs, 
heart, and organs in the abdomen, when oppressed with too much 
blood, or inflamed. Often have I had to deplore my own timidity 
upon finding lymphy effusion, the undoubted product of inflamma- 
tion, in all the cavities after death. But, notwithstanding these re- 
marks, it cannot be denied, that great discrimination and experience 
are required in investigating the physiological and pathological con- 
dition of each patient. If there be cerebral disturbance, it must be 
treated on ordinary principles. The symptoms are generally vertigo, 
lethargy, or coma. We must keep in recollection the vascular state in 
which the brain and its membranes are left at the termination of the 
stage of collapse, the ecchymotic patches produced by effusion of a 
bloody serum, between the membranes, and the plug or coagulum 
found in the great venous channels. We may do a great deal by shav- 
ing the head, and keeping it cool, by frequent cupping, or application 
of leeches. Subsequently, the application of antimonial ointment to the 
head, to produce long-continued irritation, was found very beneficial. 



ASIATIC CHOLERA. SU 

The use of opium in this stage is to be suspended. I have seen it 
employed by itself, and conjoined with calomel, to restrain the 
bilious vomiting, but without effect. 

In this stage, we frequently pushed mercurial preparations to con- 
siderable extent, both internally and by means of inunction, so as to 
affect the system speedily. I cannot say they did harm in every 
case, but they often did mischief; and I was never sensible of any 
good effects. 

In this stage, blisters and other contra-irritants are serviceable; 
keeping the morbid appearances if) view, I scarcely think we were 
active enough in this respect. 

If the bowels are not moved sufficiently, the most gentle and unir- 
ritating laxatives, such as rhubarb, should be used. If the urine be 
scanty, particularly if there be pain in the region of the bladder or 
glands, draughts, composed of camphor mixture, with a few drops of 
laudanum, and a little sweet spirit of nitre, may be useful. It is 
advisable, in some cases, to introduce the catheter, which often allays 
irritation. I have seen large collections of urine in this stage, when 
not suspected. 

Many persons died in the course of the consecutive fever, from 
pneumonia, pleuritis, pericarditis, peritonitis, but slill more from 
bronchitis. This is to be expected from the morbid appearances 
found in those who died in the previous stage. Many persons died 
of old organic diseases of every organ, but more particularly of the 
lungs; as long-standing chronic bronchitis ; chronic, calcareous and 
tubercular degenerations, and emphysema of the lungs; together 
with diseases of the heart; aneurisms, and other diseases of the 
arteries. 

Treatment of Asiatic cholera, by injection of saline solution 
into the veins. — That there is a deficiency of serum in the blood in 
cholera patients, was soon suspected; and the point having been 
well established by chemical analysis, the attention of practitioners 
directed to discover the cause of the deficiency, and means were 
employed to restore the loss. 

1 have no doubl of the correctness of this view, which appears to 

DC proved by the following facts. \st. When artificial serum has 

been added by injection, and mixed with the circulating blood, the 

toma have vanished, and every appearance of health has 

been restored. (Vide page 314.) 

id. Blood drawn from the system, after the saline injection, gene- 
rally presented the natural appearance. 

i ii! ivounible symptoms have frequently returned with all the 
horror- of collapse, after copious discharge of similar fluid from the 
stomach and bowels ; and again and again has the system been 
red by venotU injection, and the patients ultimately saved. 

The bold idea of restoring the loss at once, by injecting a large 
quantity of saline solution into the venous system, occurred to the 
Oriffinal mind of the latfl Dr. Latta of Leith, who, by his unwearied 
and unremitting exertions on this occasion, contracted bad health, 
tod ifterwaidl of consumption.' lie was ably and zeal- 

• Although Dr. Latla's exertions and fate must have been well known to a number 



S12 ASIATIC CHOLERA. 

ously supported in his investigations by Dr. Lewins, who encouraged 
and assisted him, when others threw every obstacle in the way of 
his experiments, and too often gave erroneous reports of his practice. 

When first informed of what Dr. Latta had done, my mind be- 
came terrified at the contemplation of all the evil consequences 
which might result from such extraordinary means. The danger of 
air finding its way into the vascular system, the rupture of blood- 
vessels, dropsy, and the fatal effects of inflammation of veins, made 
me, as I have no doubt it did others, regard the cure as worse than 
the disease. I was anxiously urged to try the practice ; but I re- 
sisted until Drs. Latta and Lewins afforded me an opportunity of 
examining the body of a woman who had been injected. After a 
very minute and careful examination, I could discern no rupture of 
blood-vessels — no effusion of liquid into the cavities of the cellular 
tissue. In fact, I could see no appearance that was not usually seen 
in other victims of cholera, when the ordinary treatment had been 
pursued. 

I was too old to be led away by any very extraordinary expecta- 
tions of the results of this practice; and in order that we might err 
on the safe side, it was determined, after deliberate consultation with 
my kind friend and able colleague Mr. Meikle, that no one should 
be operated upon in this manner till every other means had been 
tried in vain, till the collapse was extreme, and the patient appeared 
to be in the very jaws of death. While this will be admitted to be 
the prudent course we were bound to pursue, it will be allowed it 
was not calculated to give the practice the best chance of success. 
On the contrary, in looking over the cases, my only surprise now is, 
that one of the individuals recovered by any means that human in- 
genuity could suggest. 

The substances injected were in the following proportions: Mu- 
riate of soda, gss.; bicarbonate of soda, 9 iv. ; water, lb. x.* The 
temperature was from 106° to 120°. The solution was carefully 
strained twice through leather. The salts must not be carelessly 
thrown into very hot water, and subsequently cooled, as we found 
that water at a high temperature gradually decomposed the salts, 
and the solution remained turbid. The good effects of the injection 
were rapid in proportion to the heat of the solution, but patients 
could not bear a higher temperature than that above-mentioned. The 
precautions necessary in making and using the injection are of vital 
importance. If solid saline matter be thrown into the circulation, 
death in all probability must inevitably ensue. If the solution be 
strained through linen, or a towel, no precaution will prevent minute 
portions of flaky threads from intermingling,and should even one such 
portion be injected, recovery can scarcely be expected. I need not 
speak of the danger of injecting air ; but I may relate what happened 
in the Drummond-street hospital with respect to the tubes. Reid's 

of influential men, his grave does not exhibit any monument of public gratitude, nor 
have his orphan children received any offer of support or protection. 

* We commenced this treatment on the 12th May, 1832; the solution was made in 
the proportions above stated till 21st August, after which the quantity of each of the 
salts was doubled. 



ASIATIC CHOLERA. SIS 

syringe was the instrument employed with connecting tubes; every 
precaution was taken to have the valves of the syringe in good order, 
and the tubes air-tight. At one period of our operations, twenty- 
nine cases of death took place consecutively, without a single reco- 
very ;— this happened after we had had eight recoveries out of thirty- 
four cases. The result alarmed us, and we entered into an anxious 
investigation to discover the cause of such fatality, and in the end, 
we suspected a faulty state of the tubes; they were cut open, and 
we had the mortification to discover the spiral wire corroded, with 
scales separating, and others hanging loose. There can be no doubt 
that many of these minute portions of oxidized metal had passed 
into the system with the injection. I had a conical-shaped tin ves- 
sel for containing the solution, fitted with a cover; the temperature, 
ascertained with a good thermometer, was supported by placing this 
vessel in a large tin basin containing hot water. In order to prevent 
the lodgment of particles of dust, a deal box was made to hold the 
apparatus. To show the necessity of carefully straining the solution, 
it may be stated, that at the second straining, nearly a teaspoonful 
of saline matter has been collected from the leather strainer. At 
first we used linen, or a clean towel as a strainer; and I have rea- 
son to suspect that some of the deaths may be attributed to the cir- 
cumstance mentioned above. 

The operation should be performed by two persons; one to open 
the vein, introduce the tube, and keep it in position; the other to 
take charge of the fluid to be injected, and the apparatus. It is 
necessary to have an assistant at hand to do any thing that may be 
required, so that the attention of the operators may be entirely de- 
voted to the parts they have to act. The position of the operators 
is a matter of some consequence, as the operation will occupy fully 
half an hour; the person whose duty it is to open the vein, should 
be comfortably seated on the side of the bed corresponding to the 
arm on which he is to operate ; the other should be seated across a 
form, or narrow table, with the vessel placed between his legs. His 
first duty is to pump the thud through the tubes for a few minutes, 
iu order (<> get rid Of any air that may he attached lo any part of the 
syringe, or sides of the lubes — the extremity of the tube being kept 
Under the surface of tin; liquid. When the vein has been opened, 
and the DOele introduced, the operator is to keep it in Us place with 
the finger end thumb of the left hand, and take hold of the extremi- 
ty of ihe lube with the right; he is lo place his index iinner lo stop 
the mouth of (he lube, it being Still under the surface, while the oilier 
I'M gently pushes the piston down— this is to satisfy him that it 
is mil ; he then directs the point towards the nosle, which, if not tilled 
with blood, ought to be filled with the injection before the lube is 
finally conneeied wiih it. All this, to insure success, must he quickly 
and dexterously .done* Hppn.a signal given by the fust operator, 

the Oth0r is to eoluUieuee pumpim.', 1-elliL,' careful lo hold ll)e syringe 

perpendicularly, and never take Ins eye from the vessel, or direct his 
attention t" any other mailer. The whole of the thud, consisting of 
ten pounds, may be with safely introduced in thirty minutes; iu 
which tune we may reasonably suppose the blood will have per- 
il 



314 ASIATIC CHOLERA. 

formed the circulation several times, and the injection been mixed in 
a very gradual manner with the vital fluid. All danger of over- 
loading the system suddenly, and rupturing vessels, is in this manner 
avoided. 

It was wonderful to witness the effects speedily produced by the 
injection. These I shall now state under the following heads: — 

1st. On the pulse. 

2d. On the cramps. 

3d. On the temperature of the body. 

4th. On the respiration and voice. 

5th. On the expression of countenance. 

6th. On the restlessness, and other uneasy feelings. 

1th. On the thirst. 

8th. On the secretion of urine. 

9th. On the period of death. 
1st. On the pulse. — It is remarkable how speedily the injection 
affects the pulse, making it perceptible after it had ceased to be felt 
at the wrist. By the time four ounces were introduced, the pulse 
could generally be distinctly counted ; and when about three pounds 
were introduced, it became a tolerably good one, although it might 
be still feeble, and perhaps rapid. At last, when the pulse became 
of natural strength, the injection was suspended for a little. The 
quantity injected depended principally upon the state of the pulse, 
and we were always glad when the object was effected with the 
smallest quantity of fluid. At the same time, as we sometimes 
found the pulse flag again, requiring an immediate repetition of the 
injection, we became careful not to discontinue the operation too 
soon. 

2d. On the cramps. — The effect on this symptom was quite re- 
markable ; they generally ceased as soon as the pulse became good, 
and seldom troubled the patient again. Many cases that appeared 
to us hopeless from age, and the ravages of previous disease, were 
injected solely with a view to mitigate the sufferings of the patients, 
produced by cramps. 

3d. On the temperature of the body. — The effect on the animal 
heat is also almost instantaneous ; the body, which could not pre- 
viously be heated, now becomes warm, and instead of a cold, damp 
exudation on the surface, there is a gentle and genial moisture. 

4th. On the respiration, 8,-c. — The respiration, however weak 
previously, soon became stronger. It sometimes happened, when 
about 4 lbs. of the injection were introduced, that the respiration 
became rather laborious, which generally gave way after more fluid 
was thrown into the system. The voice, which had been whisper- 
ing, now became quite natural. 

5th. On the countenance. — In proportion as the pulse and the 
temperature were restored, so did the countenance improve. The 
eye, from being sunk, became prominent; the shrinking of the fea- 
tures, and the dark colour of the face and of the body, generally dis- 
appeared. The expression, in fact, became animated, and the mind 
lively. 

6th. The restlessness and uneasy feelings vanished. The de- 



ASIATIC CHOLERA. 315 

spondency, vertigo, tinnitus auriunr, precordial oppression, gave way 
to pleasurable feelings; and I have not unfrequently seen patients 
sit up in bed immediately after the operation, in perfect possession 
of themselves, and speak with joy on the sudden transition from 
agony and death to happiness and life. 

1th. Thirst, however urgent it might have been previous to the 
operation, soon ceased after its commencement. 

SM. The secretion of urine, in general, soon returned after the 
injection ; but in this we were more frequently disappointed than in 
any of the other favourable symptoms. 

9th. The period of death was undoubtedly postponed, sometimes 
for hours, more frequently for days, and sometimes even for weeks, 
and in some cases a perfect recovery took place. 

In noticing, in a previous page, the bad effects which might na- 
turally be expected from this operation, inflammation of the veins 
was spoken of; but it is remarkable how few instances of this took 
place, and those which did occur were generally slight, and never 
appeared to be the cause of death. 

The usual and very gratifying effects of this remedy have been 
already detailed at sufficient length, to show the complete alteration 
produced on the character of the disease. But I have now to men- 
tion that rigors, severe rigors, almost invariably followed the saline 
injection. They generally commenced a few minutes after the com- 
pletion of the operation, sometimes during its performance. If there 
were nothing more to offer, the occurrence of this phenomenon affords 
proof the most decisive of a pathological change in the system, as 
DO "ne has ever seen a patient labouring under cholera shiver, or 
present any thing like a decided rigor. 

Early in our operations, several patients, who had been twice or 
thrice injected, asked me what had become of all the liquid they had 
received into their veins. This was a natural question, and had 
intensely occupied my thoughts; but however mysterious the subject 
appeared to us at the time, it was at last unravelled by watching the 
Operations of nature ; for in the course of twenty or thirty minutes 
after the injection, one <>r two very copious discharges of a watery 
fluid took place from the Btomach, without nausea, and sometimes 
there was a large watery stool. Soon after this, unfavourable syinp- 

toms again frequently took- place : all the appearances of cholera 

returned, the patients occasionally sank into a collapsed condition, 
and unless the operation was repeated, death followed. One woman, 
who recovered, was injected Biz tunes: between the first and second 
operation, three hours intervened; between the second and third, six 
hours; between the third and fourth, four hours; between the fourth 

and fifth, four day-; and between the fifth and sixth operation, 

Hrelve days. In all, (illy pounds and a half were thrown into the 

tl Ml. 

In eleven successful cases, one operation Bufficed; in these, the 
quantity varied from three to ten pounds of fluid. 

In BUI .the operation was twice performed on each 

i; the quantity injected varied from ten to fifteen pounds. 



316 ASIATIC CHOLERA. 

In another successful case, the operation was performed three 
times ; the whole quantity introduced was seventeen pounds. 

In two other successful cases, the operation was four times repeated 
in each; in one of these, twenty-four and a half pounds were intro- 
duced; in the other, thirty-one and a half. The intervals between 
the operations varied, in these two cases, from four to twenty hours. 

From memory, I may state that about one-half of those who re- 
covered after this operation, were bled or had leeches applied. One, 
for instance, was bled three times, and had sixty leeches applied ; 
and on looking back at the cases, I believe that several were lost from 
want of depletion, as febrile symptoms almost always followed the 
injection, and many of those who died were destroyed by inflamma- 
tory action in different organs. 

Short account of other substances introduced into the system 
along with the saline solution. — Finding the patients sometimes 
returned rapidly into a state of collapse, after this operation had been 
performed successfully, it appeared advisable to make the fluid re- 
semble, as much as possible, the serum of the blood, by adding albu- 
men, obtained from eggs. In the first case, we added three ounces 
to the ordinary saline solution ; and again, in three hours, four 
ounces. It was employed in several cases. It did not appear to do 
any harm, but was laid aside, as no decided beneficial effects followed 
that were not produced by the ordinary injection. Several patients, 
thus treated, besides the one whose case is alluded to above, re- 
covered. 

Quinine, and the solution of morphia, were also mixed with the 
injection — in the proportion of ten grains of the former, and ten 
drops of the latter— with apparent benefit; but our experiments 
were not repeated sufficiently often ; our operations were hurried, 
and our bodies and minds too much exhausted, to enable us to pro- 
ceed deliberately in such an interesting and responsible field of ex- 
periment and enterprise. 

Alcohol was used in the injection in one case of extreme collapse, 
and with the happiest effects for the time. The patient spoke and 
laughed, and had every appearance of being slightly intoxicated; 
but in a few hours he again collapsed, and died. 

In the Drummond-street Hospital, there were one hundred and 
fifty-six patients injected, twenty-five of whom recovered. 

An important question has often been put to me in reference to 
these cases, — " Did you diminish the proportion of deaths by this 
practice ?" It may be necessary to remind my readers of the unde- 
niable fact, that of the really collapsed or blue cases, in which the 
pulse was either so weak as scarcely to be felt, or was imperceptible 
at the wrist, one case only out of twelve recovered; I think this cal- 
culation too high, and that the number of recoveries is not more than 
one in twenty. The number of recoveries by injection has been 
already stated— it gives the proportion of recoveries to deaths as 1 
in 6 Z 6 T . 

Dr. Latta, of Leith, saved three patients out of nine in his first set 
of cases ; and in his second set, he saved five out of seven. If these 
were added to the cases in the Drummond-street Hospital, it would 



ASIATIC CHOLERA. 317 

give more favourable results; but I am not entitled to make any- 
such calculation, nor is it our wish, to stand in a more favourable 
position in reference to this extraordinary practice. Not one of 
the patients operated on had a chance of recovery by any other 
means; we saw no such miracle out of 461 cases in the Drummond- 
street Hospital. Should I ever have charge of cholera patients again, 
I shall, profiting by the experience I now possess, use the saline so- 
lution at an earlier period of the stage of collapse, nay, at its com- 
mencement, in order to lessen the thickness of the blood before or- 
ganic mischief is done, and to prevent the formation of the fibrinous 
clots so frequently, nay, almost invariably, found in the right side of 
the heart, extending into the branches of the pulmonary artery, also 
in the great venous channels in the head. It appeared to all who 
watched the symptoms, and witnessed the post-mortem examina- 
tions, that these plugs were formed during the progress of the stage 
of collapse, and not after death. 

It may be noticed, in conclusion, that consecutive fever took place 
in our injected cases, as well as in the first set of Dr. Latta's; but in 
Dr. L.-iita's second set, none of the five persons who recovered had 
any febrile movement — which that gentleman attributed to the em- 
ployment of the vapour bath for an hour before the operation was 
performed. 

It would have been easy to enlarge on every topic contained in 
this article, but a certain space having been allotted to cholera in the 
original plan of this edition, condensation became indispensably 
necessary. But I hope brevity has not been carried so far as to injure 
the facts and conclusions. I must confess, that although I always 
saw the advantage of publishing a report of the cases of cholera 
treated in the Drummond-street Hospital, with tables of results, and 
delineations of morbid appearances, I now see the necessity of com- 
pleting the work as speedily as possible. Indeed, some explanation 
is required for the delay; — our story is very easily told. — Mr. Meikle 
and I wen- anxious for some delay to renovate our shattered nerves 
fol inch a work of labour, and to allow all the elfects of excitement 

from our minds, that ore might write deliberately, and reflect 

ionately, <>u a retrospective view of all the facts connected 
with the In the meanwhile, Mr. Meikle's duties called him 

bach 10 India, and I have never had a command of time to enable me 
to lake the task in hand. It is to be hoped, however, that sufficient 
information has, in the mean time, been given, to silence those who 

! .-it our exertions, and were pleased to predict that nothing 
could be expected to spring from our investigations. It is amusing 
to hear the jeen of the idle and uninvestigating portion of the medi- 
cal community. — M x"ou areas ignorant (say they,) of the nature and 
seat <M cholera, after having opened three hundred bodies, as those 
who never examined one Bubject." If this were the exact state of 
, it can be easily shown that we are not more ignorant of 
ad the nature, and seat of cholera, than we all arc of 

ither complaint Let me ask, Who knows any thing what- 

and pathology of measles, scarlet fever, or any 

other fever, hooping-cou-h, pulmonary consumption, tetanus, ileus, 

»7* 



318 INFLAMMATION OF MUSCULAR 

hydrophobia, rheumatism, gout, and, I might have added, every 
other disease in the medical nosology? Does this query humiliate 
the profession, or tend to unrobe it of its dignity? There are many 
very worthy persons who will think it does; but I would desire to 
have my name enrolled in the list with those who, above the influence 
of professional craftiness, sought after, and exposed the naked truth, 
and who will at last command a moral influence which others can 
never attain. But our case is not quite so bad, to say the least in our 
own favour, as some worthies may think ; for if I have failed to show 
what cholera really is, it is clearly proved that cholera is not what it 
has hitherto been supposed to be. This consideration leads me to 
hope that other and more able investigators may throw more light 
upon the subject. 



INFLAMMATION OF THE INTESTINAL MUSCULAR 
AND CELLULAR TISSUES. 

I scarcely believe that acute inflammation ever primarily affects 
the muscular and cellular tissues. On dissection, they are certainly 
frequently found altered in appearance and structure by inflammation 
and its consequences, but never, according to my experience, without 
distinct marks of the diseased action having extended by contiguity 
from the mucous and serous tunics. This part of pathology, how- 
ever, is still open to future investigation ; and the subject is merely 
introduced, to show that it has not been entirely overlooked, and to 
mention one symptom which is generally supposed to distinguish 
inflammation of the muscular coat from that of the other parts of the 
intestine, and to notice chronic inflammation, with thickening, indu- 
ration, and permanent constriction of the bowels. 

It has been repeatedly observed by writers, and has been shown 
in this work, that in pure peritonitis the bowels are generally easily 
moved by the ordinary remedies; and that, in inflammation of the 
mucous membrane, there is generally diarrhoea. Now the peculiar 
circumstance to which I have alluded, when the muscular coat is in 
a state of inflammation, is obstinate constipation. Provided a prac- 
titioner is aware that inflammation is going on in the abdomen, it is 
really a matter comparatively of little consequence, what tissue is 
primarily affected ; and it will be almost invariably observed in prac- 
tice, that those who are most apt to draw minute distinctions, are not 
the most profound thinkers. 

Portions of the alimentary canal are often observed, on dissection, 
to be thickened and indurated, and contracted in proportion to the 
thickening. The parts most frequently found in this state are, first, 
the point of junction between the stomach and duodenum ; secondly, 
the point of junction between the ileum and caecum; thirdly, the 
termination of the sigmoid flexure of the colon, or some part of the 
rectum; and lastly, the whole extent of the colon. In all these 



AND CELLULAR TISSUES. 319 

situations, the peritoneal coat is generally found sound, and the 
mucous membrane is sometimes observed to be in no other degree 
affected than being puckered; so that 1 am led to conclude, that 
although the muscular coat and cellular tissues are not so liable to be 
primarily affected with acute inflammation, yet they are frequently 
the seat of chronic inflammatory action. It must be confessed, how- 
ever, that there may be some deception here, as the inflammation 
may have extended from the mucous membrane to the subjacent 
tissues, as it has been shown that the former i3 capable of restitution, 
even after it has been in a state of extensive ulceration. The cellu- 
lar membrane of the intestines is more frequently found to be the 
seat of thickening than the muscular tunic; but occasionally we see 
the muscular fibres very much enlarged and thickened, in the state 
that has been denominated hypertrophy. This thickened condition 
of the coats of the alimentary canal, which is produced by an effu- 
sion of lymph, has been too often confounded with scirrhus and can- 
cer ; and many people are still in the habit of calling every structure 
in the body scirrhus, which is ascertained to be harder than natural. 

In general, it is impossible to determine by the symptoms, whether 
or not the parts are in this condition, except the contraction is within 
reach of the finger, at the lower part of the bowel, or is situated about 
the termination of the sigmoid flexure of the colon. When the 
thickening has been found at the pylorus, the symptoms were those 
of indigestion, attended with uneasiness after food had been many 
hours in the stomach, and when it might be supposed to be in a state 
of preparation to pass into the duodenum. When situated in the 
ileo-caecal valve, or in the course of the colon, constipation, distension 
of the abdomen, with frequent threatenings of ileus, have been re- 
marked, together with pain in the situation of the caput caecum. 

In one case, where trie colon was affected, the hardness could be 
traced during life throughout the whole extent of its tract. When 
the termination of the sigmoid flexure and the rectum, are the seat 
of the disease, besides constipation and occasional threatenings of 
ileus, the history of the case and the state of the stools will, in gene- 
ral, lead us to BUS] t tin' existence of this morbid condition of parts. 

In addition to habitual constipation, we shall fiid that there has long 
beat) in* million t<> considerable straining when at stool, which has 
gone on increasing, so as to induce the habit, which has at last be- 
come inveterate, «>| sitting and straining for a very considerable 
I, before a moderate discharge of feces can be procured; and, 
after all, the person rises dissatisfied with bis efforts, and with a full, 
mi in the belly. In such circumstances, when the 
evacuation from the bowels is of the ordinary degree of consistence, 
MS Hecet bare, as is alleged, a very peculiar form, being either of a 
worm-iik. •. shape, or flat and tape4ike; but I have little faith in this. 
The only eases which are bapabta of being cured, are those situated 
in the rectum, Which are within reach of a common bougie, or low 
down in the ftigmoi I flexure of the colon. With respect to the con- 
tractions in the other parts, much may be done to arrest the disease, 
and slleriate luffering, by attending t<> the diet, and to the state of the 
bowels. To prevent the parts running into true scirrhus or cancer, 



320 INFLAMMATION OF MUSCULAR 

the occasional application of leeches and blisters is to be had recourse 
to, and every cause is to be avoided which can have the effect of 
irritating the parts, particularly drastic purgatives. 

Scirrhus of the stomach and intestines. — In the last article, sim- 
ple induration was described, affecting various parts of the alimentary 
canal, in which the tissues were not confounded, but merely in a state 
of hypertrophy, and owing, it is conceived, to chronic inflammation, 
attended by new deposition. In true scirrhus, on the other hand, 
there is a thickening of parts, with disorganization, so as to confound 
the different tissues. It is supposed by Meckel, and other patholo- 
gists, that scirrhous degeneration commences in the tissue which 
incloses the vessels and the mucous glands, from which it extends 
itself so as to involve the mucous and the muscular coats, destroying 
their natural appearance, rendering them thicker and harder, and 
terminating at last, if the patient live long enough, in carcinomatous 
ulceration. 

Notwithstanding the great attention which has been paid by many 
eminent men to the formation of scirrhus, it is still involved in mys- 
tery. It will be found, however, to be a prevalent opinion, that it 
depends upon chronic inflammation, of a specific nature, which has 
a tendency to the formation now under consideration ; in the same 
manner that long-continued inflammation in gouty subjects, being of 
a specific character, has a tendency to deposit calcareous matter. It 
is interesting, however, to know, that the serous coat of the stomach 
and bowels is the part last affected in these cases, so that, on dissec- 
tion, it is found either quite healthy, or only slightly thickened or 
opaque-looking, still preserving its natural gloss; if there are traces 
of inflammation, they will, in general, be observed to be recent. In 
two preparations only have I seen tubercles projecting from the 
serous coat, while the other structures were affected with scirrhus; 
one of these, a cancer of the stomach, is now in my museum. There 
is always a difficulty in examining an indurated part with a view to 
ascertain the state of the vessels ; but I think I have seen the veins 
much thickened in their proper coats, not in the part itself, but in the 
second texture in its vicinity. In the soft cancer, which particularly 
affects the stomach, I have repeatedly seen vessels, supposed to be 
veins, thickened and enlarged, and on two or three occasions, a cream- 
like fluid was found in them. 

Scirrhosities are most frequently found in the situations enume- 
rated under the last head, viz.: the pylorus, the caput cascum, and in 
the course of the rectum, which may be attributed, so far, to these 
parts being more exposed than others, to be irritated by the sub- 
stances which have to pass through them. Scirrhosities may also, 
however, exist in other parts, more particularly near the cardiac 
orifice; they are sometimes extensive, so much so as to involve the 
whole of the stomach, and sometimes a large portion of the intes- 
tine. 

Fungous excrescences, of a cancerous nature, are rarely met with 
in comparison to the scirrhous indurations; nevertheless they have 
been found in every part of the alimentary canal, and were probably 
denominated polypi by the older writers. Brechet has lately de- 



AND CELLULAR TISSUES. S21 

scribed a case, which appears to me to be of this kind, under the 
name of polypus, which extended from the cardiac orifice into the 
duodenum. This kind of affection is noticed in Professor Monroe's 
excellent work on morbid anatomy of the gullet, who has denomi- 
nated it the melt-like cancer. It certainly so far answers the descrip- 
tion, because it is white and soft ; but being fibrous, cannot be washed 
away or softened down like a melt; it rather resembles a young 
placenta well macerated. Cancerous excrescences are also some- 
times found in the rectum. Meckel says they are more frequently- 
seen in this part of the bowel than any other; but they differ con- 
siderably from those found in the stomach, which are more soft and 
spongy, and less pendulous. 1 have several times met with a white 
projection, almost the size of a pea, from the mucous membrane of 
the stomach and bowels. The base is sometimes broad, at others the 
tumours hang by a narrow pedicle. Perhaps this is the white tuber- 
cle of authors. I have a preparation showing these bodies along 
with open cancer of the stomach; indeed, my museum is very rich in 
this department of morbid anatomy. 

Symptoms of cancer of the stomach, fyc. — In the early stages it 
cannot be distinguished from dyspepsia; and sometimes, even to the 
very last, the symptoms are not more severe. There is a preparation 
in my museum, showing a section of the stomach, more than half 
an inch thick, exactly like fibro-cartilage; and although the whole 
stomach presented the same appearances, the symptoms were those 
of ordinary dyspepsia. En general, however, there are progressive 
emaciation, restlessness, fever during the night, thirst, sallow colour 
of the skin, and shooting pains extending in different directions from 
the part affected. In scirrhous or cancerous affections of the stomach, 
we are generally able to tell whether the cardiac orifice, or the pyloric, 
is principally affected; if the former, pain is experienced in attempt- 
ing to swallow as soon as the article gets low down in the oesophagus, 
where it is felt to lodge; frequently the patient is obliged to force it 
up by eructation, from the pain excited by its presence, but which 
ceases as Soon as the food passes into the stomach. The pain is 
sometime bo great, thai patients avoid eating till nearly famished; and 
MOM hass described to me, that they experienced as much dillieulty 
in introducing ■ tableepooufnJ of milk, or any other 11 1 j id, as from a 
mouthful of solid food, Hut when the disease EB situated in the body 
of the HSOSBCh, the food may pass readily in, but occasions so much 
■OfierilMJ, that the patient is obliged to discharge it by voluntary 
eliorts to vomit; somet mies a considerable quantity of serous fluid is 
discharged by eructation, as in water-brash. When the pylorus is 
ail'. -i-te.l, u will be bond that the uneasiness does not become very 
great for some tide after taking food, particularly if motion be avoided, 
but at length the pain becomes intense, nausea Is excited, and the 

only temporary relief lor the unhappy sulfercr, is to get rid of the 

nsToiidiag matter by vomiting, On some occasions there is ardent 
thirst wuh baminsj pain, and the patient describes his sensations as 
if lus un ma ns: wmt corded to (be spine. When he changes his pos- 
ture in bes%bs feces tip Stomach falling from side to side, in the same 
manner that a woman for some days after delivery feels the uterus. 



322 INFLAMMATION OF MUSCULAR 

Feculent matter is occasionally vomited; this happened lately in a 
remarkable case under the care of Mr. Mitchelhill, and to whose 
kindness I owe a valuable preparation of the parts. A large oval 
opening was found in the centre of a cancerous mass in the stomach 
communicating with the transverse arch of the colon. In all cases 
the pain is increased more or less on pressure; and in some the in- 
duration may be felt, but I imagined only when the whole stomach, 
or a considerable portion, is affected. In one case the stomach was 
felt by myself and others at the umbilicus, and the woman placed 
our hands upon it ; but in that instance the whole stomach was in- 
durated, in some places thickened to the extent of more than an inch, 
with such a diminution of its cavity, that it could scarcely hold six 
ounces of alcohol thrown in, after it was removed from the body, in 
order to distend it. The immediate cause of death, in a considerable 
number of cases, is acute peritonitis, occasioned by the contents of 
the stomach passing into the abdomen through an ulcerated opening. 
This happened in the case alluded to above, and my museum contains 
several such specimens. 

Cancerous affections about the head of the colon and the rectum, 
but particularly the former, are apt to give rise to symptoms of ileus. 
There is, in general, great irregularity of bowels; they are either con- 
stipated or loose. The evacuations are more than usually fetid, and 
there is a pain of a shooting character in the situation of the disease. 
If in the caput caecum, there are frequently considerable fulness, and 
increased tenderness on the application of pressure; if the disease be 
confined to the rectum, frequent tenesmus and excoriations about the 
anus may be expected, together with lancinating pains and consider- 
able discharge of sanguineous-looking matter when the disease is far 
advanced. 

Causes. — The disease appears to our senses to be produced by 
accidental causes; but it is probable, that as pathology advances, it 
will be found to depend upon some other circumstances, perhaps upon 
original formation, either independent of, or connected with, specific 
action in the capillary arteries or veins. The woman from whom 
the stomach was taken which was so much indurated, had been for 
many years a notorious dram-drinker ; she attributed the commence- 
ment of her complaint, and I believe truly, to a blow received eight 
months before her death, in the region of the stomach. A gentleman 
who had a large cauliflower excrescence in the stomach, had been 
all his life fond of good eating and drinking, and, perhaps, raiher in- 
dulging in these respects; yet he was strong and healthy, and had 
no complaint till he received a fall from his horse one night returning 
home from a jollification. He pitched upon his shoulder, and sus- 
tained such a contusion, as induced him, I believe for the first time 
in his life, to seek for medical advice. The doctor purged him well 
with drastic medicines, till he made the poor man really sick ; and 
then, being resolved to make a good job out of a bad customer, 
fancied he discovered some obscure disease of the liver, and as he 
knew mercury to be a remedy for affections of that organ, he mer- 
curialized him well, so much so, that he kept up a salivation for many 
weeks. During this period, the patient felt, for the first time, that he 



AND CELLULAR TISSUES. 323 

had a stomach ; his appetite became impaired, and as the doctor 
knew that tonics were good for that, he sent many bottles of such 
drugs. Bark, steel and bismuth, were at last had recourse to, but, 
alas ! the patient got weaker and weaker ; the doctor grew tired of 
his patient, and the patient dissatisfied with his doctor, so that they 
parted, as it were, by mutual consent. Some time after this he fell 
under my care, when the symptoms of scirrhus of the stomach were 
so decided, that I had not the slightest hesitation in giving an opinion 
to that effect. 

The history of both these cases is quite distinct; and a great many 
such might be quoted, in which the commencement of the affection 
could be traced to a particular cause ; but it would be a pathological 
error to assert that the disease in the one case was owing to the blow, 
or in the other, to the specific action of mercury. 

Treatment. — Although no means hitherto devised will cure car- 
cinomatous affections, yet a great deal may be done in the way of 
checking the violence of the disease, mitigating suffering, and pro- 
longing life. The chief circumstance to be attended to is to avoid 
eating any article which is likely to produce irritation. In very bad 
cases, patients have been much benefited by ass's milk, and have 
even recovered considerable flesh and strength under its use ; thin 
arrow-root and gruel are to be tried; if ass's milk cannot be procured, 
fresh whey, with or without an addition of cream, is to be substituted. 
If the body still emaciate, additional nourishment may be thrown 
into the rectum, in the shape of beef tea, mutton broth, &c. The 
bowels must always be attended to; and the best manner of doing this 
is by an injection of senna and castor oil, administered every second 
or third day, as may be necessary. If the patient be teazed with 
vomiting, and worn out by pain, the most likely method of allaying 
both, is to exhibit small, but repeated doses, of the sedative solution 
of opium, which, after trying every other means, I have found to be 
the best. Should the pain, however, still persist, a few leeches may 
be applied; or if the patient be very weak, contra-irritation is to be 
produced with the ointment of the tartrate of antimony. Frequently, 
when iln: patient feela a little better after this treatment, his relatives 
will !)-• found anxious to force nourishment upon him, such as beef- 
t' i. animal jellies, and even wine; but they seldom fail to produce 
an increase of suffering in severe cases; therefore, physicians should 
!»'• particularly careful to impress upon friends the necessity of at- 
tending strictly to the regimen prescribed. 



CHAPTER VIII. 
DISEASES OF THE LIVER AND SPLEEN. 



In this chapter, I shall treat of Inflammation of the Liver ; Ab- 
scesses; Tubercular Formation; and Scirrhus; also of Jaundice; 
Gail-Stones; and Diseases of the Spleen. 



INFLAMMATION OF THE LIVER. 

Acute inflammation of the proper substances of the liver is of 
comparatively rare occurrence in this climate: I believe that the 
peritoneal coat of this organ is more frequently the seat of the dis- 
ease, and that inflammation of the liver is often confounded with 
functional and structural derangement in neighbouring organs.* I 
have seen some remarkable cases of this within these few years. 
One dissection revealed pericarditis, another inflammation of the in- 
ferior lobe of the right lung, and a third a collection of matter in the 
thorax; all of which had been mistaken during life, and treated for 
hepatitis by sundry courses of mercury ! 

The liver, like other viscera, may be affected with inflammation in 
various degrees of intensity and extent of surface; and these will 
give rise to symptoms of corresponding severity ; but it will be suffi- 
cient to describe the acute and chronic hepatitis. 

Some are of opinion that acute hepatitis is an inflammatory con- 
dition of the hepatic artery, and chronic of the vena portse ; Wins- 
low asserted, that each had its origin in the ramifications of the vena 
porta?; but it is easier in such matters to make assertions than to 
bring forward good proof. The truth is, that we are ignorant of the 
matter; and although an interesting pathological question, yet it does 
not appear to me to be one of much practical importance, at least in 
the present state of our therapeutical knowledge. 

[*"Dr. Bell, who has written on the diseases oflndia, describes two forms of acute 
hepatic inflammation, which are different as to their seat and character. In one of 
these, which he terms sero-hepatitis, the disease is on the surface of the liver : in the 
other, which he terms puro-hepatitis, it exists in the centre. In the sero-hepatitis he 
stales that the patient is attacked with sudden pain in the region of the liver ; and this 
is so severe that even the weight of the bed-clothes is insupportable ; the patient 
cannot bear to turn, or to lie on his left side, from the pressure exerted in that position 
on the inflamed organ. But the deep-seated, or puro-hepatitis may go on in such a 
latent manner, that the first symptoms you have of liver disease are those which mark 
the occurrence of suppuration."— Dr. Stokes's Med. Rep.] 



INFLAMMATION OF THE LIVER. S25 

Symptoms of acute hepatitis. — The acute and sub-acute varieties 
almost always commence with some chilly feelings, succeeded by 
heat of skin; furred tongue having a yellowish appearance; irregular 
state of bowels, the stools being generally costive, like whitish clay, 
or dark-coloured at first, and assuming the whitish appearance as 
the disease advances. Sometimes there are vomited and passed by 
stool, considerable quantities of dark-coloured matter, occasionally 
resembling grumous blood; but this generally takes place, it would 
appear, when there is great accumulation of blood in the liver, and 
also in the vessels of the mucous membrane of the intestines. The 
urine is scanty and very dark-coloured; the skin hot, dry and harsh; 
there is some degree of dyspnoea and anxiety of countenance, to- 
gether with nausea and vomiting, which are sometimes intractable, 
and considerable thirst. The pulse is sometimes, but not always, 
quick, strong and hard. In the most acute form, the pain in the 
region of the liver is severe, increased on pressure, accompanied by 
swelling and tension of the abdomen; pain is occasionally experi- 
enced about the top of the right shoulder, which is supposed by many 
to be pathognomonic of an affection of the liver; but nothing is more 
deceptive. The patient prefers lying on the right side. This com- 
plaint, whether slight or severe, is liable to be mistaken for affections 
of the neighbouring viscera, more particularly of the stomach and 
duodenum, and the serous membranes which cover both surfaces of 
the diaphragm, as well as inflammation of the lower lobe of the right 
lung. These are attended by some degree of cough, which, in many 

- of hepatitis, is a marked symptom. A yellow discoloration 
of the skin, known in common language by the term jaundice, oc- 

Mially takes place in hepatitis, as does hiccup; but neither the 
one nor the other, nor both conjoined, can be said to be symptoms 
peculiar to hepatitis. When the inflammation affects the peritoneal 

of the liver, the pain is much more intense, generally speaking, 
and tlif fever higher, than when confined to the substance of the 
liver. Nothing is more unsatisfactory than the result of external 
■ •\ unination, made to ascertain the condition of the liver when sus- 
d to labour under disease. The contraction of the muscles of 
ili<- abdomen ; distension of tie- colon or stomach ; disease of the kid- 
neys; a collection of matter in the thorax pressing down the dia- 
phragm, art; all sources of deception. The patient is to he placed in 

inch a posture as will relax the muscles of the abdomen, which will 

he besl effected when lying in bed with tin- head and shoulders well 
Ited by means of pillows, and tin' knees drawn up towards the 

abdomen. In tins position the examination is to be made ■ percussion 
is i.i lie employed, to inform us whether there is any flatulent dis- 
tension ; and the patient should he fasting. He should he told to 
take a full breath, when pressure is to he made in the region of the 
liver, while the lungS are yet distended. With all these precautions, 

little v .t,-.! nil, ,n will, 111 general, he obtained from the examination, 
liver be very large, because the right lobe is the pan most 
frequently afiected, which is concealed by the false ribs The ste- 
thoscope will afford satisfactory negative information respecting die 

condition of the lungS, In the SCUtfl dis-asr, the patient may die 
28 



526 DISEASES OF THE LIVER. 

either from the rapid destruction of the liver, or from the extension 
of the inflammation to surrounding parts. 

Symptoms of chronic hepatitis. — This disease is very slow and 
insidious in its progress, and uncertain in its termination. There is 
a dull dragging pain in the right hypochondrium, increased by any 
considerable exertion, attended occasionally by feverish symptoms, 
and a dry, parched skin, irregular bowels, scanty high-coloured 
urine, tympanitic distension of the abdomen, sallow countenance, 
and frequent attacks of jaundice. The pulse is much affected, per- 
haps, for some time. On many occasions the patient is cut off by 
an acute attack of inflammation in a part of the liver which had not, 
perhaps, been previously involved in the disease, or from peritonitis, 
or from inflammation of the lungs or pleura. There may be pain in 
the shoulder, and sometimes a weakness of the right arm ; the tongue 
is scarcely ever free from yellow fur, and is seldom very dry; the 
appetite is bad, and an eruption very often attacks the face and back 
between the shoulders, generally in the form of acne; the patient 
passes bad nights, although he may be able to attend to his ordinary 
affairs through the day, and is frequently teased with diarrhoea, tenes- 
mus, and piles. In the chronic disease the patient may die dropsical, 
or sink under acute inflammation of the peritoneal coat. 

We are assured by Mr. Twining, (in his Clinical Illustrations, &c. 
p. 146,) that inflammation of the liver is often far advanced (in Ben- 
gal) towards suppuration without the patient having suffered much 
pain ; but he has never known a case terminate in abscess, without 
being able, by careful examination, to detect the disease in progress 
long before there was any reason to believe that suppuration existed. 
Among the diagnostic marks of central abscess of the right lobe of 
the liver, is a much greater degree of tension of the right rectus ab- 
dominis muscle than the left. — (P. 14S.) 

Mr. Twining introduces the subject of diseases of the liver, by 
remarking that they " occur so often among Europeans, in combi- 
nation with the fevers and alvine fluxes of Bengal, that it is hardly 
possible to give a correct and complete account of hepatic affections, 
without alluding to (he cases wherein fever or dysentery may have 
been the original or more important complaint, to which the liver 
affection has supervened." — (P. 135.) 

Jlppearances on dissection. — The following are the appearances 
most frequently found in acute cases of hepatitis in this country. 
Adhesions between the liver and surrounding parts; fulness or en- 
largement, the organ having lost much of its elasticity ; easily broken 
down between the fingers, its edges thick, and more rounded than 
natural. The colour will depend much upon the quantity of blood 
in the vessels of the organ; but in general it will be of a brighter red 
in the inflamed portions. It must, however, be kept in recollection, 
that venous engorgement produces discoloration of the liver; and 
sometimes reduces it into a pulpy state. In either case, the distinc- 
tion between the red and whitish-yellow parts of the liver is de- 
stroyed. In those affected with jaundice, the colour of the liver will 
have a similar tint. The termination by abscess is by no means rare 
in tropical climates, and it is sometimes seen in this country, although 



INFLAMMATION OF THE LIVER. 327 

I believe that tubercular degeneration in a state of softening, is not 
unfrequently mistaken for abscess. This termination of hepatitis in 
the formation of abscess, is, however, not always fatal. The matter 
may escape in various ways: — Is/. Externally through the parietes 
of the abdomen, by the intervention of adhesive inflammation be- 
tween the peritoneal surfaces. 2d. It has been expectorated, after 
finding its way through the diaphragm into the substance of the 
lungs. 3d. It may find its way into some part of the intestinal tube, 
and pass off' by stool. I have seen instances of all these termina- 
tions, the patients recovering partially, but never completely, although 
permanent cures are said to have taken place after such events. The 
matter has escaped from the liver into the cavity of the abdomen — 
into the thorax— the gall-bladder. [A single example of this kind 
has occurred in my own practice: the purulent evacuations were 
abundant and of long duration; and, from the attendant circumstances, 
I have no question of their hepatic origin. " Two instances of re- 
covery," says Dr. Chapman, " I have known myself. The first of 
these was the captain of a ship in the India trade, and the second in 
a lady of this city, both of whom had unquestionably abscess of the 
liver, and were permanently cured, after immense evacuations of 
pus, upwards and downwards."*] Andral alludes to a case in 
which an abscess of the liver communicated with the interior of the 
vena cava, and another with the pericardium. 

Mortification is, I believe, unknown as a termination of hepatitis; 
it is often mentioned by the older writers, who called every part 
which was dark-coloured and soft by that term. 

Under the sub-acute and chronic forms of hepatitis, there is, per- 
haps, a greater variety of morbid appearances. The following are 
the principal alterations observed, viz.: enlargement ; hardness; con- 
traction ; (atrophy;) granular appearance increased, sometimes di- 
minished •. red parts increased, and whitish; yellow parts diminished; 
or victverad. We sometimes Bee the liver variegated green ; a brick 
colour ; sometimes there are darkish-red bodies in a yellowish ground, 
ellowish bodies in a red ground, at others greenish bodies in a 
bright yel ow ground. The whole liver is sometimes converted into 
a ib ■ . the surface of which looks of a mottled green, with 

projections from its surface of different sizes: a section produces a 
thick, tenacious, bloody exudation, and when wiped away, leaves 
the surl ice of a curious variegated appearaisce, containing spots, some 

the si/.-- 'it' a half crown. Others smaller than a sixpeuee, pf ;i yellow 

colour, streaked with red and white lines, each spot appearing to 
bave a di tincl centre, with red and white lines running towards the 
circumference, In a case of ibis kind, of which I have drawings, 
the cystic duet was d the gall-bladder much distended with 

coloured viscid bile, and its coats greatly thickened. In many 
hronic inflammation of the liver, I have distinctly traced 
increa • l \ iscularity in the vena porta' and its branches, together 
with thickening of ih< to Btich n degree as to re- 

MDll Similar appearances are to he observed 

also in the lower anni 

[• Lectures on son. \ th<_- thoracic md abdominal viscera, p. :;| " i 



328 DISEASES OF THE LIVER. 

Mr. Twining mentions having observed tumours, varying from 
the size of" a grain of barley to that of a bean, situated in the capsule 
of Glisson. According to this gentleman's observation two small 
bodies can always be found by dissection, which he believes are ab- 
sorbent glands. One of these bodies is situated near the termination 
of the gall-bladder, in the cystic duct; the other at the upper part of 
the ductus communis choledochus. He thinks enlargement of these 
bodies, with inflammatory excitement about the capsule of Glisson, 
may cause an obstruction, and in some cases obliteration, of the 
biliary ducts.— (P. 142.) 

Causes. — There can be no doubt that the disease is more frequent 
in warm climates than in this country, and still more so in the East 
Indies than the West; which shows that heat alone is not a specific 
cause of hepatitis. Indolence, along with full living on high-seasoned 
food, and a neglected state of the bowels, are, I imagine, the principal 
causes of hepatitis in all climates ; and when to these are added high 
temperature, atmospheric vicissitudes, and constant and copious 
perspiration, it is no wonder that the disease should be very prevalent 
among Europeans in India. We are assured by Mr. Twining, that 
Europeans recently arrived in Bengal are very liable to liver dis- 
eases, from exposure to atmospheric vicissitudes, or to the common 
causes which produce fever in Europe; and that habitual plethora, 
and an abundance of stimulant food, beyond the real wants of the 
constitution, doubtless to keep the greater number of Europeans in 
India in an almost perpetual state of high predisposition to inflam- 
matory and suppurative disease of the liver. (P. 153.) In this 
country, dram-drinking is an alleged cause; but I believe this per- 
nicious habit produces disease of the stomach more frequently than 
of the liver. A congested state of the vessels of the liver must also 
tend to produce inflammation of its substance ; hence it often succeeds 
to intermittent and remittent fevers. Various other causes have 
been assigned ; but for these, and for many valuable observations, 
the reader is referred to the various works published by authors who 
have had the charge of sick in India. But it is with pleasure that I 
take this opportunity of earnestly recommending every medical man 
going to India, or any similar climate, to take with him Mr. Twin- 
ing's works.* 

I believe that women are more liable to diseases of the liver than 
men in Great Britain, owing probably to their sedentary occupations; 
but it is confidently stated by Mr. Twining, (p. 256,) that in India, 
European women are less liable to acute liver diseases than men of a 
corresponding class of society, by reason of their more temperate 
habits of mind, as well as less exposure to the exciting causes, and 
more abstemious mode of living. But they are liable to insidious 
diseases of the liver after fevers, and in consequence of disorder of 
the digestive organs. Diseases of the liver are well known to be a 
frequent consequence of chronic phthisis. 

Treatment. — The more intercourse I have with intelligent practi- 
tioners, who have been in India, the more I am convinced that the 

* The London publishers are Messrs. Parbury, Allen & Co., Leadenhall-street. 



INFLAMMATION OF THE LIVER. 329 

action of mercury has been too much trusted to, to the neglect of the 
lancet, and particularly of local bleeding; and that drastic purgatives 
are too much in use. Therefore I would recommend the lancet, in 
the early part of the disease, to be used with decision ; but if it be 
too far advanced, the application of leeches may be trusted to, toge- 
ther with gentle laxatives, frequently repeated, assisted by injections. 
I have a high opinion also of long-continued contra-irritation ; but to 
act beneficially, it must be persevered in, and assisted from time to 
time by local abstractions of blood. Occasionally, the solution of 
tartar-emetic may be given, if the stomach be not already in a too 
irritable condition. Mercury may be used, as a powerful assistant to 
these means, rather than as the principal remedy; perhaps it may be 
found, in such cases, to be more useful in restoring the proper func- 
tions of the liver, after diseased action has been reduced, than in 
reducing that action itself. The warm bath is to be frequently em- 
ployed. The diet should be of the blandest description, and the 
patient must avoid fatiguing exercise, particularly on horseback, for 
a considerable time after his convalescence. 

"The object in the treatment of severe acute cases of hepatitis,' 1 
says Mr. Twining, p. 155, "is considerably to diminish the quantity 
of circulating fluid, and permanently to subdue the action of the heart 
and arteries ; and by abstaining from food, and taking very little 
drink, at the same time that we use purgatives, to keep the system so 
empty and low that absorption shall be performed with activity. 
This condition is to be maintained by a steady perseverance in pur- 
gation, and repeated vascular depletion, until we have effected the 
dispersion of the vascular turgescence, and absorption of that inter- 
stitial deposit, more or less of which exists in almost all acute inflam- 
mations of the liver, very soon after the disease commences. Sup- 
posing tin: patient to be first seen in the morning, an active purgative 
should be given, and he should be bled from the arm to one pound 
and a half, or two pounds. The bleeding must be repeated every 
mx hours, until llu: pains in the side and fulness of epigastre are 
relieved. Three hours after the second bleeding, 80 leeohea should 
be applied." Again, he Btates that, " in all severe cases of hepatitis, 

the patient's life depends on systematic pursuance of general ami local 

blood-letting, with quiescence, and strict attention to almost entire 
i ion of food; even drink should betaken in limited quantity 
while we are endeavouring to empty the vascularsystem." — (P. 15(5.) 
Mr. Twining States, thai when the disease is severe in India, re- 
moval 10 a colder climate is considered essential, and remarkable re- 
coveries have taken place during the homeward-bound voyage. 
It must not be supposed, from my statement regarding the limited 
if mercury, that I have joined the standard of those who perti- 
naciously resist the employment of mercury in all diseases, and who 
insist that every little eruption, or accidental disease of a bone, or 
chrome, ulceration of the throat, is produced by the action of mer- 
cury, although the individual may not have taken a grain of it for 
twenty or thirty j 

■ id that mineral waters, as those of Cheltenham and 1 farrow- 
gate, arc found v useful in diseases uf the liver, as also 

28* 



330 DISEASES OF THE LIVER. 

the nitro-muriatic acid bath ; and I think benefit has been derived 
from the use of iodine, but it becomes me to speak doubtfully re- 
specting these remedies. Chronic hepatitis, and other diseased spates 
of the liver, are to be treated pretty nearly upon the same principle; 
except drawing blood from a vein, which is rarely called for; whereas, 
the action of mercury is likely to be more beneficial than in the 
acute form of the disease. 

Much mischief is done in this country generally, and particularly 
in South Britain, by the conduct of many medical practitioners, who 
denominate every little indisposition "a fit of the bile," and attribute 
a great deal too many of the phenomena that daily present themselves, 
to disorder of the liver. They either pour mercury quickly into the 
system, or keep people for months under the gentle influence of an 
alterative course of blue pill, with an occasional five-grain dose of 
calomel, followed by a drastic purgative next day. All this is too 
frequently done when nothing whatever ails the liver, the complaint 
consisting of a vascular slate of the mucous membrane of the sto- 
mach and duodenum; the cause of which is, perhaps, some error of 
diet, or persevering in eating more than the wants of the system re- 
quire, or drenching the stomach with too much liquid. Many exam- 
ples of this description fall under my care annually; in which a pro- 
perly restricted diet, gentle, unirritating laxatives, a warm bath twice 
or thrice a week, and the application of a contra-irritant to the 
epigastric region, occasionally, for a month or six weeks, produce as 
much relief as can be expected after years of maltreatment and 
quackery. 

I have a few words to say respecting scirrhus of the liver and 
tubercular formation. The true scirrhus of this organ is, I imagine, 
as rare as mortification; and as a congested appearance is often mis- 
taken for mortification, so is tubercular formation for scirrhus. A 
diseased state of liver, corresponding to scirrhus in other organs, is, 
however, occasionally seen, and is to be distinguished by its indura- 
ted condition, and its white bands. Another appearance, similar in 
every respect to medullary sarcoma, is occasionally observed, of 
which I have seen two or three instances, and possess drawings taken 
from two cases. Sometimes tubercular formation may be traced, 
extending from the peritoneum into the substance of the liver : the 
peritoneum having a thickened, opaque, and sometimes puckered 
appearance, occasionally contracted inwards, so as to give a resem- 
blance of loss of substance from the discharge of an abscess. On 
some occasions, the tubercular masses project from the surface of the 
liver, producing a lobulated appearance. Sometimes, however, the 
peritoneum looks perfectly healthy, although there may be consider- 
able enlargement of the organ itself; and when cut into, large tuber- 
cular masses are discovered, sometimes near the surface, at others 
deep-seated, whieh look yellow, and resemble the general tubercular 
infiltration which takes place in the lungs. The liver is sometimes 
found studded with yellow bodies of different sizes and shapes. The 
organ is of a reddish tint, and these bodies look like yellow wax 
sunk into the texture. They are not like tubercles. Andral con- 
siders that they are merely the white substance in a state of hyper- 



JAUJNDICE. 331 

trophy. Laennec believed them to be an accidental tissue found in 
the liver, and termed the disease cirrhosis. Sometimes the peritoneal 
coat only is studded with tubercles of the miliary kind, in various de- 
gress of progress, some being quite vesicular, and others crude. 

We sometimes meet with a liver of a pale or bright yellow colour, 
exceedingly soft and tender, containing a large quantity of oil. This 
is called the fatty liver, and although most frequently seen in phthisi- 
cal subjects, is yet met with when the lungs are not diseased. A 
liver in this condition, looks, when superficially observed, of uni- 
form colour, but when minutely examined, there will be seen minute 
brown, red, or greenish spots or lines on a yellow ground. Some- 
times the fatty liver does not exceed the natural size, at others it is 
greatly enlarged. I have seen one so large that its inferior margin 
extended rather beyond the brim of the pelvis. Another weighed 
nearly 16 pounds; large sections of this liver floated even in strong 
alcohol. Sometimes the fatty matter is not universally infiltrated 
through the liver, but deposited in small masses here and there. 
[Fatty liver is also a very frequent occurrence in persons who have 
lived intemperate lives.] 

A preparation of a diseased liver was presented to me some time 
ago, in which there was a large effusion of lymph thrown out be- 
tween the diaphragm and the liver, with adhesions round the edges, 
which closely resembled a tuberculated liver. 

Cysts containing hydatids are sometimes found in the substance 
of the liver, sometimes two or three in number, containing large 
quantities of these vesicular bodies. Various opinions are enter- 
tained respecting the origin of hydatids, but after an attentive con- 
sideration of the whole subject, and a minute examination of the 
bodies themselves, I think they are not animals, but ought to be 
regarded as diseased products like tubercles. 



JAUNDICE. 

It has already been stated, that jaundice is not an invariable 
Attendant on hepatitis. It would seem occasionally to depend upon 
B of the gall-bladder and biliary duels, perhaps inflammation. 
It is sometimes occasioned by obstructions of various kinds, as thick- 
ening and obliteration of the ducts, and during the passage of gall- 
stones. I have seen jaundice where no morbid appearance or 
mechanical cause of obstruction could be discovered after death. It 
iiiiisi In: confessed that much remains to be done in the anatomy, 
physiology and pathology of the liver. Jaundice may be produced, 
however, by one or other of the following causes: diminished secre- 
tion of bi!-', greatly increased secretion, viscidity of the bile itself, 
acute or chronic disease of the liver and gall-bladder, inflammation 
and obliteration of the biliary ducts, obstruction from gall-stones, and 
possibly, by spasm of the ducts. 

Phenomena," Jaundice takes place, as has been already stated, 
M an occasional symptom Of hepatitis, but sometimes it occurs 
suddenly in cases where there could have been no acute action, or 



S32 DISEASES OF THE LIVER. 

disorganization of any kind, and preceded by languor, some degree 
of restlessness, diminution of appetite, flatulent distension, and other 
symptoms which attend indigestion, nausea, vomiting, and dull pain, 
or sense of weight in the right hypochondrium. The tongue is 
generally furred and yellow ; the urine scanty, commonly of a deep 
yellow, sometimes tinged green, and occasionally like the grounds of 
porter; bowels slow, and the evacuations whitish. The tinge of the 
skin is somewhat preceded by a tingling or itching of the whole 
body, and the colour of the surface is various, from that of pale 
citron, almost to black. The conjunctiva of the eye partakes also 
of the colour. Occasionally there is some fever, and the nights are 
disturbed. Jaundice sometimes comes on insidiously ; at others, 
suddenly. Thus, I have known a man to sit down to dinner in 
tolerably good health, and be soon obliged to retire, from feeling 
indisposed, with his whole surface suddenly tinged; the first circum- 
stance which excited attention was a remark which fell from him- 
self, that the table-cloth was of a greenish colour. This observation 
leads me to remark, that I have known several individuals who saw 
every object discoloured. 

Treatment.— The treatment of jaundice is not well understood. 
When it accompanies disease of the liver, it must be treated as a 
symptom ; if it seem to proceed merely from functional derange- 
ment, the warm bath, one or two emetics, and continued laxatives, 
should be employed, together with a gentle course of mercury. If 
there be pain, the application of leeches may be necessary, conjoined 
with contra-irritation. Great attention must be paid to the diet also, 
which may be more or less antiphlogistic, according to the urgency 
and duration of the symptoms. The nitro-muriatic acid bath has 
appeared to be serviceable in many cases. [Dr. Johnston, of London, 
announces that he has succeeded in curing several very severe cases 
of jaundice, with inspissated ox-gall, in doses of five grains, gradually 
increased to ten grains, three times a day. We confess ourselves at 
a loss to explain the probable modus operandi of this substance ; and 
Dr. Johnston himself appears to attribute the benefit derived from it 
to the fact of its being the best substitute that can be found for the 
human secretion.] 



GALL-STONES AND WORMS. 

As long as gall-stones remain in the bladder, they seem to be pro- 
ductive of little annoyance. I once found two hundred and forty in 
the gall-bladder of a subject, whose history was not known ; but on 
several occasions, I have met with them after death, in which no 
suspicion of hepatic disease had existed. Sometimes there is only 
one calculus, which fills, or nearly fills, the gall-bladder; and I owe 
a very splendid preparation of this kind to the kindness of Dr. Combe 
and Mr. Cheyne of Leith. 

Gall-stones create pain, it would appear, only when they are in 
the act of passing towards the intestine. In such circumstances, the 
patient is seized with violent paroxysms of pain, during which his 



[GALL-STONES AND WORMS.] 333 

sufferings appear to be as great as any human being can well endure ; 
he ascribes his sufferings to spasms. The abdomen is sometimes 
painfully distended by flatus ; it is very curious, however, that the 
pulse frequently remains quite natural during a paroxysm, although 
sometimes it is rather accelerated. The bowels are sometimes con- 
stipated, at others diarrhoea takes place, and a considerable quantity 
of mucus is occasionally discharged. 

Treatment. — We have to direct our attention, in this case, to 
moderate symptoms. Sometimes bleeding will be productive of 
relief; at others, it does not seem in the least to mitigate the pa- 
tient's sufferings, but I conceive it to be good practice to open a 
vein in a strong, plethoric person. The warm bath, and hot fomen- 
tations, are to be frequently employed. Large doses of opium are 
to be exhibited, and the bowels must be carefully and daily attended 
to. It may be mentioned also, that leeching and cupping are some- 
times necessary. [The emetic treatment recommended by some 
physicians, is not always allowable: yet it will often relieve the 
paroxysm in a decided manner, and by relaxing the duct, assist the 
passage of the stone. Where, however, the attacks are frequent, 
this passage requires caution or the stomach may sustain a permanent 
injury. I have lately met with a case which is relieved only by 
emetics, and in which I cannot doubt that small concretions have 
repeatedly passed into the intestine. 

The liver and its appendages, like various other parts of the hu- 
man organization, are occasionally infested with worms. The most 
remarkable of these is called the Fluke, (Fasciola hepatica, and 
Distoma heputicum of naturalists) which is found in the gall-blad- 
der and biliary duct. It has a flattened, elongated oval form, rather 
pointed at each end. There are no characteristic symptoms attend- 
ant on the presence of these worms, which belong equally to man 
and several of the inferior animals, and especially in the sheep, con- 
stituting the disease called the rot. 

The liver is not unfrequently the seat of worms of the hydatid 
kind, of which the following have now become familiar to the re- 
searches of the pathologists. 

1. Jicephatocyati* endogena, which infests the liver in vast num- 
bers, hut always encysted. They are sometimes found after death, 
without having occasioned any appreciable disorganization or dis- 
during life. In other instances they form a large tumour in the 
hypochondriac region. 

I, Echinococctu hotninis. — This parasite, observes Dr. Farre, 
closely resembles the preceding one, and is found not only in the 
liver, bul also in the spleen, omentum and mesentery. It consists, 
like the former, of a simple bag, which appears to be formed of two 
1, to the inner one of which are appended other animalcules of 
the following kind : 

limaleuli tchinococei.— These creatures, says Dr. Farre, are 
fly remarkable for being u the parasites of a parasite," for they 
floating in the cavity of the echinococcus.] 



334 DISEASES OF THE SPLEEN. 



INFLAMMATION OF THE SPLEEN. 



It is not easy to determine when the spleen is inflamed, for when 
found diseased, on dissection, there have been no symptoms during 
life which could be said to indicate disease of this organ more than 
any other in the abdomen. In all probability this matter is not likely 
to be discovered, until we know more of the physiology of this or- 
gan. It is occasionally found diseased in this country, but still oftener 
in warm climates, more particularly in situations where intermittent 
fevers prevail. It has been known to weigh above eight pounds; 
sometimes it is hard, but most generally we find it, when diseased, 
soft like a coagulum of blood; it is in such circumstances that the 
erectile tissue is best seen, a fine specimen of which is in my muse- 
um. The spleen, like the liver, is also subject to the formation of 
tubercles, both in its substance and capsule. In two or three cases 
of tuberculated spleen, which were examined minutely, I found the 
tubercles almost spherical, each inclosed in a capsule. 

Some time ago, a preparation was presented to me, of a large ab- 
scess in the spleen, the walls of which were partly formed by the 
stomach and diaphragm. In the centre of the abscess, a portion of 
spleen, the size of a large nut, was found quite detached. In the 
thorax, the pleura, covering the corresponding part of the diaphragm, 
was inflamed, and the interior surface of the right lung adhered. In 
this case, there were no symptoms to show that the spleen was af- 
fected. The patient died after amputation of the leg, which was 
performed with great reluctance, after the occurrence of mortifica- 
tion, as the only chance of prolonging life; extensive disease of the 
arteries was discovered. There is a splendid dried preparation in 
my museum, showing the state of parts. 

Inflammation of the spleen is said to be recognized by heat, ful- 
ness and tenderness in the proper region, with pain on pressure : 
for instance, Cullen has given the following definition : " Pyrexia, 
tension, heat, tumour and pain in the left hypochondrium, increased 
by pressure, without any signs of nephritis." 

Discharge of livid blood from the stomach and bowels has often 
been observed during life, in cases where extensive disease of the 
spleen was afterwards discovered on dissection ; but the same thing 
happens from other causes. 

A new light is thrown on this much neglected subject, by the pa- 
thological investigations carried on by Mr. Twining, at the General 
Hospital at Calcutta. I feel that no apology will be necessary to my 
readers for the following long extracts from Mr. Twining's work 
already quoted. I place more confidence in the writings of this gen- 
tleman, from the gratifying accounts I have from time to time re- 
ceived from several of my former pupils, of the zeal of the writer, 
and the correctness of his facts. 

"Diseases of the spleen," says Mr. Twining, " may be deemed 
important, not only by reason of their frequency, severity, and the 
danger with which they are attended in Bengal ; but on account of 
the change which the constitution undergoes previous to their ori- 



INFLAMMATION OF THE SPLEEN. 335 

gin, and during their existence ; as well as the modifications which 
they produce on the nature and tendency of other diseases, that may 
occur at the same time. Instead of viewing the enlargement of the 
spleen as the principal object for investigation, it will be consistent, 
with a correct view of the disease now under consideration, to speak 
of the enlargement of the spleen as one of the phenomena usually 
attendant on a peculiar description of constitutional disorder. The 
characteristic symptoms of this disorder are generally debility, pale- 
ness, and a deficiency of red blood in the capillary system of vessels; 
this is most remarkable in the pale and bloodless aspect of conjunc- 
tiva, hectic blneness, or pearl colour of the sclerotica, and chlorotic 
discoloration of the visage, tongue, and gums. The circulation is 
generally languid, and the extremities are apt to become cold; the 
skin pale, shriveled and arid. In the chronic disease, affecting 
emaciated subjects, we often find a dry furfuraceous desquamation 
of the cuticle. We sometimes see a chronic enlargement of the 
spleen in adults of pale, sallow and unhealthy aspect; who eat and 
drink as they did in health, and seem to endure the disease for 
many months without much suffering, except the inconvenience of 
a tumid belly, attended with shortness of breath, and occasional 
returns of indistinct ague. The disease is far more distressing to 
children: in them, if careful attention to diet and correct medical 
treatment be omitted, the enlargement of the spleen, and corre- 
sponding decay of general health, are in most cases progressive, and 
they sink into a state of marasmus. In fact, a person who has ar- 
rived at a mature growth and strength, may exist for a while, with 
a degree of induration and enlargement of the spleen which is in- 
compatible with growth, or even the continuance of life, in those 
below puberty, for we find that children with this disease, soon 
become poor, languid, weakly creatures; whose breath and the ex- 
halations from their bodies, have a nauseous, sickly odour, indicative 
of tin; unsound state of their constitutions. This distressing and 
obstinate malady is not peculiar to the natives of this country, nor 
is it confined to the poorer order of Europeans. I have observed 
the disease in its severest form, to come on after fevers, affecting the 
children of wealthy Europeans, who lived in every comfort, and 
Vers attended with the greatest care. It is not unfrequently ac- 
COtnpanied, in such patients, by the extreme degree of constitutional 

ier, which marks its advanced stages in the poorer classes of 
natr. 

■• Females affected with enlargement of the spleen, are liable to 
Buffer lioui amenorrheas; and cases of spleen disease, in which the 
periodical return is not obstructed, may, for the most part, be con- 
lidered as having a Favourable prospect of recovery. During the 
continuance! of vascular engorgement of the spleen, patients are very 
prone to foul sloughing ulcers, from slight wounds or bruises; and 
when local inflammations exist, those peculiar characters of active 
inflammation, and that healthy constitutional energy, on which de- 

. >ii ol coagulable lymph depends, and by winch we find injuries 
rep lired, and us extension of ulceration, as well as the progress of 



336 DISEASES OF THE LIVER AND SPLEEN. 

sloughing, arrested on ordinary occasions, seem to be in great mea- 
sure, if not entirely subverted. 

" Blood drawn from veins varies much in appearance; sometimes 
it coagulates imperfectly and no serum is separated ; in other cases 
the cruor is black and soft, and after being exposed to the air, its 
surface does not generally assume that more florid colour which we 
observe on the top of a coagulum of blood drawn from the vein of 
a healthy person, and it seldom exhibits a buffy coat, except when 
ardent pyrexia is present, or when the disease is attended with acute 
pain in the side. The serum, when heated, coagulates as firmly as 
that of a healthy person, but the coagulation is more friable, and less 
tough ; and this coagulated albumen frequently has a slightly yellow- 
ish appearance ; sometimes it has a greenish colour. 

"Several of the characteristics of scorbutus are present during the 
vascular engorgement of the spleen: there is a tendency to haemor- 
rhage from slight causes or injuries ; leech-bites, blisters and issues 
are apt to ulcerate during the rainy season ; and at times the slightest 
ulcerations are apt to slough. Foul gangrenous ulcers of the lips and 
gums, are liable to form in consequence of slight local irritation, (and 
often without any obvious cause,) whereby the jaw bones become 
carious, and exfoliate, and the teeth fall out. Haemoptysis as well as 
haematemesis occasionally occur when the spleen is very large, and 
probably the blood which is vomited sometimes flows into the 
stomach from vessels communicating directly with the splenic vein, 
as the intumescence of the spleen has been observed, in some cases, 
to be immediately reduced by these evacuations of blood. It is true, 
that profuse haemorrhages from the nose, lungs, or stomach, some- 
times suddenly destroy life ; but we see other cases, where the func- 
tions of the system not having been much disordered previously, the 
patients recover quickly after these profuse losses of blood ; and the 
disease of the spleen is thus entirely cured. The results of these 
spontaneous haemorrhages should not be forgotten, in deciding on our 
plans of treatment in ordinary cases of spleen disease. 

" Most patients, with enlargement of the spleen, are affected with a 
short and imperfect respiration ; the general appearance of the patient 
evincing that decarbonization of the blood is insufficiently accom- 
plished, and every attempt to take active exercise excites panting and 
distress at the chest. Among the usual attendants on vascular en- 
gorgement of the spleen, we may observe impaired appetite, diffi- 
cult digestion, and imperfect assimilation of the food. There is gene- 
rally despondency and depression of spirits; inactivity of body and 
torpor of mind, with much muscular debility; and this latter symp- 
tom is remarkable, although the patients be not much emaciated. 
When active pyrexia is not present, the urine is pale, often copious. 
In the latter stages of the disease oedema of the feet is present, and 
sometimes the face and eyelids are swollen. The majority of pro- 
tracted cases that terminate fatally, suffer from dysentery, or dropsy 
of the belly; and when the abdomen is much distended from this 
latter cause, the superficial veins on the side of the chest and belly 
appear large and numerous; showing the extent and degree to which 
the circulation in internal organs becomes ultimately obstructed. 



INFLAMMATION OF THE SPLEEN. 337 

"Diseases of the spleen often occur in conjunction with dysentery, 
intermittent and remittent fevers, scorbutic affections, and sometimes 
with the diseases of the liver. 

"The tumefaction of the spleen occasionally comes on very sud- 
denly, in the course of remittent fevers, in Bengal ; and in a few days 
the enlargement can be seen as well as felt, extending far below the 
cartilage of the left false ribs. The degree of enlargement which 
takes place is variable ; it is very common to see the spleen extending 
downwards on a level with the umbilicus; and laterally, from its 
usual situation, as far as half-way between the cartilages of the ribs 
and navel. In extreme cases the diseased spleen fills more than half 
the belly, extending to the right of the navel, while its lower extremity 
reaches the left iliac region. Several cases of this enormous tume- 
faction may be seen every year in Calcutta; and some of them 
recover. Besides the globular tumefaction of the spleen above men- 
tioned, there is a more oblong enlargement, in which the anterior 
edge of the organ is felt deeply indented with fissures. In this de- 
scription of disease, there is more induration than attends the globular 
tumour; and the patients are cured with greater difficulty. This is 
considered by the native practitioners a very dangerous and intrac- 
table form of the disease. 

" The greater number of cases of the affections above described, are 
unattended with local inflammation ; although there is almost always 
morbid sensibility on pressure being made over the left hypochondre, 
during the early stages of enlarged spleen ; and sometimes slight pres- 
sure over that part causes exquisite pain. Splenitis, or acute inflam- 
mation of the peritoneal coat of the spleen, would appear to be a rare 
disease ; it sometimes exists without much enlargement of the organ, 
and then the symptoms very much resemble plenntis of the leftside; 
doubtless splenitis is occasionally cured, by the antiphlogistic treat- 
ment pursued, when pleuritis is supposed to exist. Pain in the left 
shoulder is rarely present. 

"The progress of vascular engorgement of the spleen is more or less 
rapi'l, according to the injury which the constitution may have suf- 
fered from damp 'innate, and the nature and duration of the fevers 
whuh iln- patient may have recently suffered. 

« Enlargement of the spleen Borne times appears as an idiopathic 
tse in children, and in persons of delicate and feeble roust it in ion; 
and is produced by the combined influence of a damp climate, varia- 
ble temperature, want of exercise, unsuitable clothing, and insufficient 
nourishment, during the slow and Bilenl influence <>f long-continued 
grief and distress of mind; the secretions generally appear to be 
perverted, the cutaneous circulation becomes languid, healthy trans- 
piration obstructed, and then we often find enlargement of the spleen 
take place in Bengal, The disease, when dependent on such causes, 
b always difficult to cure. The most part of the cases of vascular 
engorgement of the spleen in this country, follow intermittent and 
remittent fevera; and tumid spleen may be stated as the most inva- 
riable ennseqnences of act im attd debilitating diseases among' children 
of weak const it nt iona in Bengal. The same sort of enlargement 

takes plac.! here m ihe spleen of adults, in consequent: <>f various 
19 



338 DISEASES OF THE LIVER AND SPLEEN. 

debilitating diseases, (but more especially after protracted remittent 
and intermittent fevers,) which we occasionally meet\vith at all sea- 
sons; but they are seen in their worst forms about the latter end of 
the rains, and commencement of the cold season, just when concen- 
trated exhalation and considerable diurnal changes of temperature 
co-exist, which repress the action of the skin, and force the circulating 
fluids on the internal organs of the body. At that season of the year 
congestive fevers are frequent, and lamentably fatal at the low and 
damp situations in these tropical regions. These fevers prevail not 
only in the country forming the delta of great rivers, but in the 
marshy situations at the foot of hills and mountains, where the soil 
is composed of alluvial and vegetable remains, washed from the 
neighbouring hills into situations where there is no drainage, and an 
imperfect ventilation. The assemblage of constitutional symptoms, 
described in the foregoing pages, constitutes the endemic cachexia of 
those tropical countries that are subjected to paludal exhalations. 
The enlargement of the spleen is the most frequent attendant on this 
cachexia ; and its increase, or subsidence, generally corresponds 
with the unfavourable or favourable changes which are taking place 
in the constitution. It is, however, proper to observe here, that the 
constitutional symptoms sometimes exist in a very marked degree, 
where neither enlargement'nor morbid sensibility of the organ itself 
is very palpable. 

" On dissection of subjects in whom disease of the spleen has ter- 
minated fatally, we find a considerable variety in the morbid appear- 
ances of that organ, which may be described under the following 
heads : the most frequent diseased appearances being placed first in 
order. 

"1. — A soft rounded enlargement of the spleen, the texture less 
firm than in the healthy state, and easily broken if the finger be 
pushed abruptly against it. In some cases the part is so much soft- 
ened, that it resembles a great clot of blood, wrapped in a thin mem- 
brane; this varies in colour from black, to brown or blue, and in the 
extreme degree of softening, when we attempt to lift the tumid spleen, 
the fingers are thrust through the membrane, and the organ breaks 
down in the hands, becoming a putrid gore. This soft globular 
enlargement, from vascular engorgement of the spleen, most com- 
monly attends, or follows, the severe remittent fever of the rains and 
cold season, when that disease attacks weak and unhealthy young 
persons. 

"2. — Oblong enlargement of the spleen; the organ being more 
firm in texture than in its natural state, its edge thin and notched ; 
the colour being sometimes a pale brown, though more generally a 
dusky red. This morbid change of structure would appear to be the 
result of more slow and gradual degeneration, which, in its earlier 
stages, has probably been attended with some inflammatory condition 
of the internal structure of the spleen ; in such cases we also find evi- 
dence of superficial inflammation attended with adhesions to adjacent 
parts, more frequently than in the rounded enlargement from simple 
vascular engorgement. 

" 3. — Opaque patches of various sizes; some of these extend over 



INFLAMMATION OF THE SPLEEN. 339 

half the convex surface of the spleen, and are nearly l-8th of an inch 
thick; they may be deemed the result of albuminous depositions 
during superficial inflammation. 

"4. — Adhesions of the peritoneal coat of the spleen to contiguous 
viscera; which adhesions are by no means a general result of tumid 
spleen in Bengal. 

" 5. — In a few old cases, we find a more indurated friable spleen, 
that breaks when handled without much force, like a piece of old 
moist cheese. 

"6. — Still more rare, is the firmer induration intersected with septa 
of condensed fibrous structure; to which we give the name of scir- 
rhus. 

"7. — Tubercles of various sizes, generally small, and of gray or 
brown colour. 

"8 — An organized coagulum in the splenic vein. 

"9. — Encysted tumours. 

"10. — Abscesses of the spleen. 

" The four last-mentioned morbid appearances are extremely rare 
in Bengal. 

"Besides the above appearances of disease, we sometimes see an 
uniform pale white, or milky colour of the peritoneal coat of the 
spleen, which tunic is unusually tough, like a thin bladder that had 
been dried and afterwards wet in hot water, the substance of the 
spleen being soft and flexible. This has been observed in the post- 
mortem inspection of persons who had been long subject to agues. 
In patients who have suffered from spleen disease, and are destroyed 
by a purging, numerous small ulcers are found on the internal mem- 
brane of the great intestines, while the peritoneal coat appears either 
quite healthy, or paler than usual ; the mesenteric glands, in such 
subjects, are often enlarged. 

- Our treatment of the early stage of enlargement of the spleen 
must depend much on the nature of the co-existent pyrexia, and the 
degree of morbid sensibility, when pressure is made over the left 
hypochondrium, as well as the nature of other acute symptoms that 
may be present. We would also be much guided by the degree of 
plethora, and general condition of the patient. Bin mercury must 
never be Dee I with a view to cure the diseases of the spleen. 

« The treatment found most useful in that modification of enlarged 
spleen, which COdsistfl in vascular engorgement of the organ, is per- 
severance in a course of purgative medicines, combined with bitters, 
and some preparation of iron, of which small doses of the sulphas 
ferri appear to be the most efficacious. My usual formula, for cases 
where there is not much pyrexia, is, Pulv. jalap. — Pulv. rhu., Pulv. 
Columns*. — Pulv. zinziberia — Potassae Bupertartratis, tut .si. Ferri 
sulphatis, 3s& — Tinct. sennas, \w. Aqua? months Batirse, 5x. Misce. 

"Tins prescription is called the spleen mixture. 4 The dose is one 
ounce and n naif t « >r an adult, at c, a. m. and repeated at 11 a. m. 

Bcacy of preparation ol iron in ill" cure of enlarged spleen, la pointed oat 
i Materia ndedica, rol. iT. page 901. aa well aa i" 

le Phllosophii|M(', vol. iii. j. .i ••■■ f>17. Nus ill' R<" 

act 5. 



340 DISEASES OF THE LIVER AND SPLEEN. 

daily. For children, the doses are regulated so as to produce not 
less than three, and not more than four stools daily. This medicine 
acts as a purgative, tonic, and diuretic. The purgative properties in 
the two first articles in this prescription, will be assisted by the cream 
of tartar, while that medicine with the jalap generally acts on the 
kidneys ; the principal effects of the other ingredients, may be re- 
ferred to their tonic and astringent properties. The cure of the 
enlarged spleen, may probably be, in some measure, owing to the 
effects produced on the circulation in that organ, by the frequent 
application of a powerful astringent to its immediate vicinity. The 
natives of this country are decidedly of that opinion ; for, on admi- 
nistering remedies containing sulphate of iron in spleen disease, the 
patient is commonly directed to lie on the left side, that the medicine 
may flow to that part of the stomach in contact with the spleen. I 
have formerly used the above prescription with treble the proportion 
of sulph. ferri now directed; and on dissection of some young sub- 
jects, who came under my care in an advanced and desperate stage 
of the malady, and who died of the diseased spleen while taking the 
mixture with the larger proportion of sulphate of iron, I found the 
stomach quite white, and exceedingly contracted, more resembling 
a man's thumb than a young child's stomach. I now consider the 
smaller quantity of sulph. ferri more proper for ordinary cases ; and 
sometimes add 3i of pulv. scam mo n. comp. to the above mixture, for 
patients who are very costive, and require stronger purgatives. On 
the other hand, in very delicate and emaciated subjects, who are 
easily purged, it is requisite to substitute compound tincture of car- 
damoms for the tincture of senna; and if there be any disposition to 
paroxysms of intermittent fever, I add to the mixture the same 
quantity of quinine as it contains of sulphate of iron. 

" When the disease is obstinate, there is an advantage in changing 
the prescription occasionally; and after the above has been used for 
10 days, the patient, if an adult, is directed to take eight grains of 
compound extract of colocynth, with two grains of gamboge, in pills, 
at bed-time; and 20 drops of tinct. ferri muriat. in a wineglass of 
water, with 3i of tinct. gentian, comp. at 7, and repeated at 11a. m. 
These medicines are to be continued for five days ; and then, after 
taking the spleen mixture for ten days more, the patient is ordered 
to take 3ss of the powder of black myrobalan, with 3ss of black 
salt, every morning; and eight grains of compound extract of colo- 
cynth, with two grains of sulphate of iron, and two grains of aloes, 
in pills at bed-time. Thus, for two-thirds of the time, the patient is 
taking the spleen mixture, with the occasional change to another 
medicine for a short interval, whereby the efficacy of the principal 
remedy is not weakened by its habitual use. It cannot be of im- 
portance to adhere invariably to a precise number of days in using 
each prescription, but an occasional change is requisite; and at any 
time during the treatment, if the patient becomes feverish, the above 
medicines are omitted, a dose or two of jalap is given, and leeches or 
venesection employed. In a few cases, we find enlarged spleen 
attended with cough, and the febrile stage of catarrh; and these 
cases are better treated for a few days by venesection or leeches, 



INFLAMMATION OF THE SPLEEN. 341 

purgatives and tepid bath, before we begin the mixture containing 
sulphas ferri. 

» As a general plan of treatment for Europeans, those adult sub- 
jects, who are not much reduced in strength, must be bled from the 
arms, and have from four to ten leeches applied over the region of the 
spleen every second day, for a fortnight. Should there be pyrexia, 
the venesection should be repeated once or oftener ; the blood should 
always be taken while the patient is in the recumbent posture, and it 
is seldom requisite to take more than one pound of blood at a time 
from an adult. In all cases where fever exists, or venesection is 
requisite, I have found much benefit from directing a purge of com- 
pound powder of jalap, or of scammony, with cream of tartar, and 
a grain of gamboge, to be repeated for two or three days before the 
sulphate of iron was administered in combination with bitters and 
purgatives, as above directed. 

" In the treatment of diseases of the spleen, a careful attention to 
regulate the patient's diet is of the utmost importance. During the 
continuance of fever, the nature and quantity of food must be directed 
with reference to the degree of pyrexia, and symptoms of local in- 
flammation that may exist. When patients not much reduced in 
strength are suffering from the early stage of vascular engorgement 
of the spleen, and having only occasionally slight pyrexia, it is 
advisable that the medicine should be given twice a day, so as to 
operate freely three or four times; no meat should then be allowed; 
they must live on tea, bread, sago, gruel, and chicken-broth or kid- 
soup, in very small quantity. But in the more chronic cases, where 
we must patiently wait for slower changes in the constitution, and 
the gradual removal of the enlargement of the spleen, the mixture is 
given once daily, in the morning, and in such doses as to act less 
powerfully only twice a day. It is then not inconsistent to allow 
some roasted or boiled meat, and curry. A small quantity of port- 
WVOB and water, or beer, is also taken with benefit at dinner time, in 
most cases where meat can be allowed with propriety. 

'< Natives Buffering under the early stage of spleen disease, attended 
with fever, live on barley-water, sago, bread, and coce, or parched 
rioe j but in more chronic forms of the disease, they may with safety 
be advised to eat their usual curry and rice. It seems generally 
admitted that milk is improper food for patients labouring under 
of the spleen, and I am now quite satisfied that the prohi- 
bition of milk is almost always justifiable. The native practitioners 
also prevent patients from eating fat, or oil, although castor-oil is 
Often administered by them u B purgative, and with great beneflt. ,, 



25' 



PART III 



DISEASES OF THE ORGANS CONNECTED WITH THE RESPIRATORY 
SYSTEM. 



CHAPTER I. 

GENERAL REMARKS ON DISEASES OF THE 
RESPIRATORY SYSTEM. 



In approaching the subjects which are to be treated of in this part 
of the work, I gladly seize the opportunity of expressing the greatest 
admiration of the talents and powers of observation of the late M. 
Laennec, and of acknowledging that he is the individual of this age 
to whom the science of medicine stands most deeply indebted. I 
know not which to admire most — the extreme patience with which 
he carried on his investigations in diseases of the chest, or the zeal 
and tact which he displayed in surmounting the obstacles which must 
have daily come in his way. 

The diseases of the chest were once the opprobrium of medicine; 
and although we are still liable to be mistaken, yet by percussion 
and auscultation, we are enabled to judge correctly of the nature 
and seat of some affections which otherwise would be mere matter 
of conjecture. 

It is scarcely more than half a century since Avenbrugger sug- 
gested the probability of ascertaining the state of the organs within 
the thorax, more perfectly, by percussing the chest with the points 
of the fingers. M. Corvisart translated Avenbrugger's Treatise into 
French, and subsequently brought the practice of percussion into gene- 
ral use and great repute. It must be confessed, however, that percus- 
:<'ii i> a much teas satisfactory practice than auscultation, either with 
or without the stethoscope, which instrument is the invention of Laen- 
nec, and which is now too well known to require any description in 
this work. 

A great deal of opposition has been made, and many frivolous 
"!'!• wtiuus have been urged against the employment of auscultation, 
principally by three classes of practitioners. 1*/. Those who are 
too well employed, and who have not time to learn any thing new. 
Bat Those who are dull of hearing, or devoid of the power of dis- 
criminating between sounds which have sonic resemblance to each 
Other, '-id. Those who are. too indolent or too old. 

With respeel to the first daaft) 1 need not say much, as no observa- 
tions of mine will improve such medical men, by inducing them to 
pay more ragacd to the science than to the trade of the profession. 
I'm as to the second class, I have only to observe, that it is too bad 
for men who are deaf, to decry the employment of a means which 
is found to be so advantageous in practice; and the only method by 



346 GENERAL REMARKS ON DISEASES OF 

which they can be silenced, is for others to state their defect — a task, 
which, though ungracious, I shall not shrink from performing in re- 
spect to those whose statements are likely to influence the too nume- 
rous " herd of imitators" in the profession. In this class, there are 
some who can hear perfectly well, but who, from the want of what 
is called a musical ear, are incapable of discriminating sounds, in 
the same manner as some are unable to detect the difference between 
a hard and a soft pulse, or a full and a sharp pulse ; or as others 
who, from a defect in the organs of vision, cannot see any thing 
twenty yards distant. Such individuals, then, will never be capable 
of availing themselves of this additional means of investigating dis- 
eases of the chest ; but they have no right to prejudice others in the 
profession, who are, perhaps, too happy to avail themselves of any 
excuse which is likely to save trouble. In the third class of objec- 
tors, I have placed the indolent and the aged. With respect to the 
first of these, 1 have to remark, that the public have not so much to 
complain of the ignorance of medical men, as their indolence and 
want of zeal ; and it is as difficult for a camel to pass through the 
eye of a needle as to make an indolent physician active and zealous ; 
therefore, it is not to be wondered at, that they should advocate the 
advantages of remaining ignorant. As for many of the aged oppo- 
nents, they act, no doubt, upon the principle which is observed in old 
dogs, of not learning new tricks. Before quitting this unpleasant 
part of the subject, it is proper to impress on those who are fond of 
indulging in sarcasms against the cultivators of pathology, that ridi- 
cule is not argument, and that perfection is scarcely to be expected 
from auscultators, any more than from others in the profession. It 
is also very unwise in any lecturer to decry auscultation, and to bring 
forward solitary instances of mistakes made by those who use the 
stethoscope, or pretend to use it, in the investigation of diseases of the 
chest. It is not very prudent in any one to run the risk of instilling 
bad principles into the minds of students, by recommending them to 
make a show of using the stethoscope in practice, and "thereby pre- 
tend to see as far into the heart of a stone as their neighbours." 
What would be said by such an individual, if the mistakes made by 
medical men in practice were brought forward by those inimical to 
the profession, in proof of the inefficacy of physic and surgery ! I 
have seen the wrong leg amputated by mistake, and the operation 
of lithotomy has been frequently most cruelly bungled ; yet no one 
is entitled, from the knowledge of many such facts, to say that sur- 
gery is altogether useless, or that there are not some clever surgeons. 

Some individuals have stated objections against the use of the 
stethoscope; they say it requires a lifetime to arrive at any thing like 
perfection. I have already shown that it requires great patience 
and good ears to learn it at all, and that those who possess neither 
the one nor the other, will never be able to use it advantageously. 
But if the difficulties of any task were allowed as an argument 
against making attempts to overcome them, it may be asked, what 
would become of all the sciences? 

They also state, that it is indelicate to examine the chest of a 
female with this instrument in any circumstance ; and that it fre- 



THE RESPIRATORY SYSTEM. S47 

quently cannot be done, in consequence of the fatigue it occasions to 
the patient. With respect to the first, I have to observe, that it is 
an objection which I should have expected from one individual only 
in the British empire— Sir Anthony Carlisle. I feel convinced that 
every professional man of experience will join me in the following 
statement, that fewer objections are started by females possessing 
delicate and innocent feelings, to any kind of examination which 
their medical adviser may think it necessary to propose for their 
advantage, than by those who unfortunately are differently consti- 
tuted. It is to be lamented that this objection is brought forward 
more in the spirit of special pleading, than with a view to benefit 
either science or good morals. It may be maintained, however, with 
truth, that the examination may be made in such a manner as not 
to occasion the slightest blush ; the patient need never be exposed, 
the different sounds of respiration being sufficiently audible for all 
useful purposes, through the texture of an ordinary nightgown. 
Instead of meeting with objections on the part of females, it has 
always appeared to me that they were anxious the investigation of 
the nature and seat of any disease in the chest should be carried out 
to the most complete elucidation. Cases no doubt, occur, in which 
it is inconvenient and painful to move the patient much; but these 
are comparatively rare, and must be so far disregarded when life is 
at stake. 

I shall now turn to a more agreeable part of the subject, by shortly 
stating a few cases, showing the advantages derived in actual prac- 
tice from auscultation. A few years ago, I was requested to see a 
patient who had been under the care of several medical men, and by 
way of giving me every necessary information, his friends put me in 
possession of all the recipes which had been recommended — they 
would have made a moderately-sized quarto volume. At one time, 
it was supposed that he had stomach complaint, and all known 
tonics were prescribed; at another, it was supposed to be scrofula, 
for which he took large quantities of the muriate of lime ; at last, he 
was BMpected to have diseased liver, and he got large quantities of 
mercury, ami was several times completely salivated. Upon apply- 
ing the stethoscope, I discovered a cavern in the superior lobe of the 
right Inng, and was doubtful whether another did not exist in the 
leu. Next day, I had the advantage of a consultation with Dr. 
Scott, whose .superior knowledge of diseases of the chest, and stetho- 
lact, I am happy to have this public opportunity of acknow- 
ledging. lie was merely asked to see a patient with me, without 
knowing the result of my previous examination, which he confirmed, 
wnli tins addition, that lie had no doubt of the existence of a cavern 
in the left lung : and it was afterwards proved to be correct. — A 
remarkable case was under my care some years ago, at a time when 
I was only beginning to make some progress in the use of the stctho- 
\ man presented himself, With many Of the ordinary symp- 

"i indigestion, and without a single sign indicative of disease 
of the lungs. I examined him carefully with my ear, with a view 
Of perfecting myself in the natural sounds elicited by respiration, and 

the tones of the voice, when, to my astonishment, I thought I dis- 



348 GENERAL REMARKS ON DISEASES OF 

covered a small cavern in the superior lobe of one of the lungs. At 
that time, Dr. Wavel, an excellent stethoscopist, was a pupil at the 
dispensary. He was requested to examine the man, without know- 
ing my suspicions. Upon comparing notes, he was of the same 
opinion. It was subsequently discovered that the man coughed a 
little in the morning, but not so much as to attract even his own 
attention ; upon dissection, some months afterwards, our diagnosis 
was fully verified. 

Dr. Henry, of Manchester, and others, will not forget the case I 
had occasion once to examine with him, in which we discovered 
empyema of the left side of the thorax, which had been treated for 
disease of the heart, by the late Dr. Buchan, because the pulsations 
were felt to the right of the sternum, instead of the left. By aus- 
cultation and percussion, we were enabled to state most confidently 
that there was extensive effusion, which pushed the heart to the 
other side of the chest. The patient did not survive above a fort- 
night, and the correctness of our opinion was fully proved, by the 
existence of an immense effusion in the left side of the thorax, 
amounting, I believe, to twenty or twenty-six pounds of fluid, with 
large masses of lymph. 

Liver complaints are often confounded with disease of the lungs, 
in which it is of the greatest consequence to the patient, that the 
physician should be able to form a proper diagnosis, which he cannot 
do, in many cases, without the assistance of auscultation and percus- 
sion. A case of this kind once fell under my notice. A physician 
treated a patient during some time for a pulmonic complaint, with- 
out knowing its exact nature or seat, which he could not fail to have 
discovered, had he been able to use the stethoscope. After a little 
time, the patient complained of uneasiness in the abdomen, and the 
liver was felt rather prominent on the right side, but pressure did 
not aggravate the symptoms. It then came out that the man had 
been in India for several years, and as that was the case, it was sup- 
posed he could not fail to have drunk plenty of arrack, and conse- 
quently to contract an affection of the liver. He was accordingly 
salivated over and over again, but the enlargement continued to in- 
crease ; and it may be briefly stated, that the man died. Upon 
dissection, his liver was perfectly sound, and it was found that the 
protrusion was occasioned by an immense effusion into the left side 
of the chest, which pressed down the diaphragm, and encroached upon 
the abdomen. 

By auscultation and percussion, we shall be always able to discover 
the existence of collections of fluid in the chest, which, by ordinary 
symptoms, cannot be ascertained. Dr. George Gregory, a late writer 
on the Practice of Physic, in his article on hydrothorax, or dropsy of 
the thoracic cavity, (627, ed. 1825,) states as follows: " The diag- 
nostic symptoms of this form of dropsy are very fallacious. 
Sometimes we are confident of finding water in the thorax, when 
that cavity is perfectly free from disease. Jit other times, we ob- 
serve the thorax full, when we had no suspicion of the complaint 
existing.'" I have no doubt after writing this paragraph, the author 
applied himself most assiduously to the acquirement of stelhoscopic 



THE RESPIRATORY SYSTEM. 349 

knowledge, without which no man can treat diseases of the chest 
with any confidence. 

It is well known, that there is a great resemblance between the 
ordinary symptoms of inflammation of the pleura, and a painful 
affection of the intercostal muscles, which is called pleurodynia; the 
resemblance is so great, that it is impossible to distinguish the one 
from the other without the use of the stethoscope. Not long ago I 
had three such cases within a short space of time; one only proved 
to be pleurisy, and that was the one in which I least expected to find 
it, from the slightnessof the ordinary symptoms. 

I have seen many remarkable cases of chronic inflammation, and 
I believe extensive ulceration in the wind-pipe, which the ordinary 
symptoms announced to be the most hopeless cases of phthisis pul- 
monalis;— there were cough, expectoration tinged with blood, ema- 
ciation, debility, rapid pulse, with bad, feverish nights, attended by 
profuse perspiration. By the sound of the respiration, and the reso- 
nance of the voice, I was enabled to assure myself that the lungs were 
as yet sound, and they were all cured by means to be afterwards 
described in the proper place. Every year I see several cases of 
chronic bronchitis which have been mistaken for phthisis, many of 
which were cured or relieved by the appropriate remedies, which 
must have terminated fatally if managed as cases of phthisis. In the 
treatment of inflammation of the substance of the lungs, it is of the 
utmost consequence to be able to tell whether the disease be exten- 
sive or nut ; whether it be in the first stage, that of active sanguine- 
ngorgement; or in the second, that of solidification; whether 
the disease be advancing or declining, which can be done by no other 
in' ana (ban auscultation and percussion. 

It b is already been attempted to be shown, of how much advan- 
tage u 1-- lo sound the chest in cases of fever. 

Much injury, it is to be apprehended, will result for some years 
me, by individuals pretending to use this instrument, and pro- 
nouncing confident opinions as to the nature and seat of diseases, 

who are unacquainted even with the natural sounds of respiration, 
and who, as 1 have often seen, do not really know bow to hold the 

st>-tli pe. Few individuals can acquire the power of using the 

instrument advantageously from books, without the personal assist- 

■iii'- one already instructed; and I have known several 
gentlemen give up the task as hopeless, because! they could hear 
nothing, but who resumed it upon being properly assisted and in- 
structed. 

On the other hand, candour compels me to mention, that much 
iel bas been done by Borne able stethoscopists pretending to 

accomplish too much; according to them, auscultation is infallible; 

but thai tins is not to be expected from any human invention, applied 
lor the purpose "i investigating <>r curing diseases, I need not waste 
time lo prove. That it is ■ great assistance, as an additional 
mxtns of diagnosis in diseases of the chest, no man possessed of the 
spun ol truth, who has fairly given h a (rial, or who has followed 
the pi ici ce of those who can avail themselves of auscultation, will 

deity, 1 maintain, without the tear of Contradiction, that perhaps 

9Q 



350 GENERAL REMARKS ON DISEASES OF 

one of the greatest advantages to be derived from auscultation, is that 
which enables us to obtain negative proof, in cases where we have 
failed in discovering positively the seat of the disease. For example, 
if a medical man be called to a case which has either been pro- 
nounced to be consumptive, or in which a doubtful opinion has been 
given, it is truly delightful for all parties, if he be able to give a posi- 
tive assurance that the lungs are not affected, although he may not 
be able to tell exactly the seat of the disease. 

Some medical men allege, that they can discover every condition 
of the lungs, quite well enough for all practical purposes, by ordinary 
symptoms; therefore I shall now take a view of these symptoms, for 
the purpose of showing the fallacy of this statement. The following 
symptoms are supposed to denote inflammation of the lungs, in the 
most satisfactory manner : Cough, dyspnoea, pains in the thorax, 
quick and strong pulse. When these symptoms exist, they are sup- 
posed to be peculiar to inflammation of the lungs; that is to say, when 
they exist, inflammation is present, and when they do not exist, the 
disease is absent. Experience enables me to state, that not one of 
these symptoms, or all taken together, indicate inflammation of the 
lungs in any of its textures, and that inflammation may exist without 
any of them being well-marked ; hence it is, that physicians are so 
often astounded with the appearances on dissection, which they did 
not anticipate from the mildness of the symptoms; and hence it is, that 
they too often decry the usefulness of morbid anatomical inquiries. 

Cough is not peculiar to disease of the lungs ; it may be produced 
in a violent degree by any kind of irritation about the larynx, epi- 
glottis, and even the pharynx ; mere excitement of the circulation 
frequently produces cough, as well as diseases of the heart. I shall 
afterwards prove, that in some of the most hopeless cases of inflam- 
mation of the lungs, the patient cannot cough, in consequence of 
which the danger is greatly increased ; therefore cough cannot be 
said to be peculiar to inflammation of the lungs. 

Dyspnoea is as frequent a consequence of disease of the heart, as 
of the lungs ; mere excitement in the circulation will produce dys- 
pnoea. One of the most distressing cases of dyspnoea which I ever 
had the misfortune to witness, dissection proved to depend on an 
enlargement of the gland which fills up the angular space at the 
bifurcation of the bronchial tubes. From a mechanical cause, also, 
oedema of the inferior, as well as the superior aperture of the glottis, 
frequently produces a fatal dyspnoea. In many cases of extensive and 
severe inflammation of the bronchi, after free expectoration, the dys- 
pnoea subsides so completely, that should a symptomatica! physician 
happen to make his visit at that period, he will pronounce the patient 
to be convalescent, when, perhaps, within an hour or two, he will be 
no more. Even in pneumonia, if the inflammation be confined to a 
small part of one lobe, which it frequently is, there is little dyspnoea; 
and the whole of one lung may be destroyed by chronic inflamma- 
tion, without occasioning much difficulty of breathing, if the disease 
go on very slowly ; therefore dyspnoea cannot be said to be peculiar 
to inflammation of the lungs. 

With respect to pain, nothing is more deceptive, for there may be 
severe pain in the chest without inflammation, as has been already 






THE RESPIRATORY SYSTEM. 351 

stated with regard to the affection denominated pleurodynia. In 
bronchitis there is little or no pain ; in pneumonia the pain is gene- 
rally little marked; and, contrary to the statement made in all sys- 
tematic works respecting the severe pain in pleuritis, experience 
enables me to state, that it may go on most extensively, even to a 
fatal termination, without much complaint; hence we often see, on 
dissection, most extensive adhesions of long standing, between the 
pleura pnlmonalis and cos/a/is, in individuals who had never been 
known to experience any serious indisposition till their last illness ; 
therefore pain cannot be said to be peculiar to inflammation of 
the lungs. 

It has already been shown, that a hot skin is not an invariable 
phenomenon in inflammation, and the same remark may now be 
made with respect to inflammation of the lungs; indeed, in bronchitis, 
the heat of the skin is frequently below par. 

It has also been stated, that the pulse cannot be depended upon 
as a certain indication of inflammation ; and in addition to the re- 
marks already made in this work, I may now state that hypertrophy 
of the left side of the heart frequently produces a strong bounding 
pulse, and also dyspnoea, when there is no inflammation going on in 
any organ of the body ; and, on the other hand, dilatation of the ven- 
tricles will produce a weak, soft pulse, at a time, perhaps, when 
every form of pneumonic inflammation is going on most rapidly. 

All Cuilen's definitions, in the sixth chapter, which treats of pneu- 
monic inflammation, are therefore erroneous, as well as the following 
paragraph, (p. 335.) " Pneumonic inflammation, however various in 
its seat, seems to me to be always known and distinguished by the 
following symptoms: — pyrexia, difficult breathing, cough, and pain 
in some part of the thorax." It will be admitted that Cullen was at 
least as wise, talented and observant as any of his symptomatica! 
brethren of the present day ; yet he confesses that he could not as- 
certain the scat of the disease by the ordinary symptoms, as will be 
seen upon perusing the 334th paragraph. " Under this title I mean 
to comprehend the whole of the inflammations, affecting either the 
i i "i the thorax, or the membrane lining the interior surface of 
that eavnv; for neither do our diagnostics serve to ascertain exactly 
the seat oi the disease, nor does the difference in the seat of the disease 
exhibit any considerable variation in the state of the symptoms, nor 
lead to any difference in the method of cure." Proving by the latter 
j. art ofthe paragraph that he must have been an indifferent practitioner, 
a* the inflammatory affections of the lungs require a different treat- 
ment in each stage; bronchitis demands a differeni plan from pleuritis, 
and pneumonia from either of the others, l venture, therefore, to pre- 
dict, that in a few yean, practitioners, even those who now ridicule 
aascultation, will be compelled, in self-defence, to have recourse to 
, litional means of diagnosis, or they will lose their practice. 
i srvations were written several years ago for the first 

edition, and u is pleasing to perceive, notwithstanding all that many 
individuals have done against the practice of auscultation and per- 
■ ii«i' has been steadily advancing; tins means of cfiag- 
Ikis been widely extending, and lbs influence of truth h;is beeq 

greater than that of prejudice. 



CHAPTER 1L 



DISEASES AFFECTING THE MUCOUS MEMBRANE OF 
THE AIR-PASSAGES. 



Under this title, I shall treat of Catarrh; Bronchitis; Inflammation 
of the Larynx; Croup, and Hoopiug-Cough; together with the af- 
fection which is sometimes known by the term Crowing Disease, at 
others Spasmodic Croup. 



CATARRH. 

When a patient is seized with chilliness, followed by sneezing, 
slight fever, impaired appetite, hoarseness, occasionally loss of voice, 
and cough, he is said to have catarrh, or a common cold. The bowels 
are generally out of order, and he has an exacerbation of fever and 
dyspnoea at night. The cough is sometimes slight, at others severe. 
A slight degree of wheezing is heard, and the disease has a salutary 
termination in a day or two by expectoration of mucus, which is dis- 
charged by occasional fits of coughing. 

Sometimes the disease is confined to the mucous membrane of the 
nose and frontal sinuses, and is known by the vulgar denomination 
of "cold in the head." 

When catarrh is a general complaint, attended by considerable 
prostration, and constitutional symptoms which are otherwise slight, 
the disease has been denominated influenza. After a careful peru- 
sal of all the accounts which have been published of the various epi- 
demics of the disease called influenza, I was unable to draw patho- 
logical conclusions as to the exact nature of the affection, till I 
suffered from an attack of the epidemic that prevailed in 1S33. Till 
then 1 had considerable doubts as to the pathology of the disease, and 
gave the subject the go-by in the former editions of this work. In 
this affection there are all the symptoms of catarrh, with extreme 
oppression and prostration of strength. These two symptoms, I can 
confidently state, are owing, in general, to an irregular distribution 
of blood and accumulation in the lungs. My attack came on sud- 
denly when taking a pleasure ride. I was only three miles off, and 
could scarcely sit on my horse on my way home, from debility: more 
than once I was on the point of giving it up as hopeless. There were 
no violent symptoms, but I recollect well an impression on my mind 
at the time, that I pitied every one who had a tendency to phthisis 
pulmonalis, as from the dyspnosa and the oppression in the chest, I 



BRONCHITIS. 353 

thought the lungs were much loaded with blood. After my recovery, 
I saw many cases of the disease, and became convinced that my im- 
pression, when sick myself, was correct. Many did die of phthisis, 
and I believe more were lost in consequence of that epidemic than of 
the cholera which had preceded it. The treatment in slight cases 
consists in confinement to bed or to one room, diaphoretics, laxatives, 
and rubefacients, together with a strictly antiphlogistic regimen. In 
severe cases, one bleeding is serviceable, followed by the treatment 
mentioned above. Convalescence should be well established before 
the patient is allowed to expose himself; and it is safe to establish an 
irritation on the chest by means of antimonial ointment. 

In considering the pathological difference between catarrh and 
bronchitis, it must be recollected, that in both, the same membrane is 
affected, but in different parts; I imagine that, in the former, the 
diseased action is a very slight sub-acute inflammation, affecting the 
mucous membrane of the nose, frontal sinuses, the larynx, and tra- 
chea. Slight cases of inflammation of the membrane lining the bron- 
chial tubes, frequently pass also by the name of catarrh, instead of 
bronchitis. 

Causes, — Exposure to cold, particularly alternations from heat to 
cold, with insufficient clothing, is the chief cause of this complaint, 
as well as bronchitis. It would appear to be of no consequence how 
cold is the air we breathe, provided the surface of the body be 
properly protected ; hence bronchitic affections are, comparatively, 
of less frequent occurrence in very cold regions than in this variable 
climate. 

Treatment. — We arc seldom called upon to treat a simple catarrh, 
unless severe constitutional symptoms have been excited by some 
accidental cause ; as constipation ; a hard fit of drinking; or a load 
of indigestible food in the stomach; when an emetic, the anti- 
phlogistic regimen, a proper course of laxatives, diaphoretics, and 
Confinement to the house, will generally be all the treatment neces- 
sary. It may In: mentioned, however, that the warm bath ought to 
commended when it can be conveniently obtained. 

Wq >oa time consulted in consequence of the inflammation 

having extended into the sir-tubes, aggravated by exposure in cold 
damp weather, when we shall frequently find the disease has already 
in id'- greal progress. This is particularly the case with the children 
of the poor, who arc badly fed and clothed, and for whom little per- 
manently effectual can be done. 



BRONCHITIS. 

I SHALL treat of bronchitis in two forms, the acute and chronic, 
ian appear to have been unacquainted with the 
latnre and seal of bronchitis, although many of them have recorded 
of the disease. Sydenham has described the affection as it 
sometimes ocean under the title Peripneumonia notha; and u 
will he found, that most authors sine.; his time have copied his de- 
scription, still remaining ignorant of the nature of the affection. 



354 BRONCHITIS. 

Hoffman's Catarrhus suffocativus; Lieutaud's Fausse peripneu- 
monie, and Cattirrh suffocant e; Sauvage's Rheuma catarrhal, do 
not differ from Sydenham's Peripneumonia notha. Morgagni, who 
may justly be regarded as the first, and one of the most successful 
cultivators of morbid anatomy, seems to have been in some measure 
aware of the nature of the chronic form of this disease; and he 
has given ample proof, in his second book, that he knew it had been 
confounded with phthisis. 

Cullen has given a good description of the symptoms of the dis- 
ease, under the term used by Sydenham, Peripneumonia notha, 
but has not added anything to our knowledge upon this subject; 
and moreover, he entertained erroneous notions of the true nature 
and seat of the disease. The same remark may be made respecting 
the later work of Dr. Mason Good. The profession stands indebted 
to Dr. Badham, now professor of the practice of physic in the Uni- 
versity of Glasgow, for pointing out the nature and seat of the dis- 
ease, in a little work he published on bronchial inflammation many- 
years ago. Before the appearance of this valuable work, the disease 
was very imperfectly understood by the best physicians of the day : 
and even now, it is surprising that bronchial inflammations are so 
much overlooked and neglected, particularly in fevers, rheumatic, 
gouty, and erysipelatous affections, as well as in the course of surgi- 
cal practice. 

Pure surgeons (by which I mean surgeons who pride themselves 
upon their powers of cutting, and boast of their ignorance of every 
thing medical,) should be told that they frequently submit patients 
to capital operations, who are at the same time labouring under 
extensive inflammation of the mucous membrane of the lungs, per- 
haps in a sub-acute form, and which does not give rise to symptoms 
sufficiently violent to attract the attention of their surgical minds. 
The patients become worse from the progress of the disease, or in 
consequence, very probably, of the agony and fright experienced 
during the period of a painful and tedious operation; the pulse be- 
comes weak, the skin cool, the face either very pale or somewhat 
livid, and the wound, of course, puts on an unhealthy appearance;, 
adhesion by the first intention does not take place, and, at the first 
dressing, the lips of the wound are found gaping, discoloured, yield- 
ing a foul discharge. In such cases, patients are too often drenched 
with wine and bark, and crammed with stimulating food, under the 
idea of preventing debility and putridity. Notwithstanding these 
remedies, the strength fails, and gin and brandy are in vain had 
recourse to; the destruction of the parts in the neighbourhood of the 
wound takes place, and the patient dies from presumed gangrene, 
which is too frequently attributed to the bad air of the hospital. I 
do not mean to assert, that all cases which go wrong after surgical 
operations are owing to the bronchitic inflammation; but I maintain 
that many are, and particularly the cases in which erysipelas follows. 
But I will say more on this subject when treating of erysipelas in 
the second volume of this work. 

Symptoms of acute bronchitis. — The symptoms excited by in- 
flammation of the mucous membrane lining the bronchial tubes, 



BRONCHITIS. S55 

vary according to the seventy and extent of the inflammation. The 
tubes of one lube may be affected, when the symptoms will be slight; 
the inflammation may be still more extensive, affecting, perhaps, both 
lungs, and the symptoms will be slight also if the diseased action be 
but moderate. 

The acute form of the disease, which I am now to describe, com- 
mences with some degree of chilliness, succeeded by pyrexia, hoarse- 
ness, dyspnoea and a dry cough ; tightness, or sense of stricture in 
the chest, and oppression at the praecordia; prostration of strength; 
loaded tongue and costive bowels. An exacerbation is almost always 
observed at night. In a day or two expectoration takes place, which 
relieves the patient for the time ; the respiration, however, becomes 
more difficult, but the cough bears no proportion to the dyspnoea ; the 
tightness about the chest is increased, along with a sense of suffo- 
cation, when the pulse becomes very rapid. The deadly paleness or 
lividness of the lips and cheeks becomes more apparent ; the counte- 
nance more and more anxious; and the patient frequently requests 
to be raised, and to have more air. A loud wheezing may now be 
heard, even at a distance from the bed-side. The voluntary muscles 
of respiration are brought into play. The patient becomes insen- 
sible ; rattling is heard in the throat ; the extremities and face be- 
come cold and livid, a cold perspiration bedews the skin, and death 
soon closes the scene. 

Sometimes cerebral symptoms take place, and headache is much 
complained of, which may be attributed to impeded circulation in 
the head. The wheezing is produced by the air-passing through 
the diseased secretion in the air-passages, and may be heard by 
placing the ear to the chest, long before it becomes so severe as to 
be distinguished by any other means. 

The cases of acute bronchitis most to be dreaded, are those in 
winch the oppression in the chest being more or less considerable, 
there is neither heat of skin, pain, nor much febrile movement in the 
pulse. In fact, these three symptoms may be said to be below par; 
no alarm is taken till suffocation is threatened, or some organic lesion 
bafl been produced ; and when, at length, the signal of distress is dis- 
played, it will be found too late to save the patient. 

The disease is very fatal in infancy and childhood; and I shall 
now mention its course and progress at these periods of life. It 
Commences in the same manner as in adults, like a common cold. 
Tin; breathing becomes oppressed ; all the voluntary muscles con- 
nected with respiration are called into play; the shoulders are in 
constant motion as well as the nostrils, and the abdomen becomes 
more prominent, by the increased action of the diaphragm during 
inspiration. Sure throat frequently accompanies the disease, and the 
child sni fers bo n iiu h pam during the act of coughing, that an attempt 
is made to suppress it; wheezing soon takes place, which is more 
decided than dyspnoea; expectoration is generally followed by miti- 
g ni. .n oi suffering, which continues fpi a longer or a shorter period, 
till more phlegm is formed. The mucus aeereted in the air-passages 
is frequently discharged by spontaneous vomiting, exactly as occurs 
in hoopiug-COUgb, Children under four or five years of age can 



356 BRONCHITIS. 

rarely be made to spit up the phlegm, unless assisted by the act of 
vomiting; but they swallow it after it has been discharged from the 
air-passages. Children refuse food, but drink greedily until the 
disease is far advanced, when they cannot take a long draught from 
want of breath. An infant at the breast sucks pretty well during 
the first stage of this affection ; but subsequently, although it seizes 
the nipple with avidity, it cannot suck for any length of time, per- 
haps not for more than ten or fifteen seconds, when it will be ob- 
served to bite the nipple very forcibly, and discontinue sucking ; it 
will cry, and be observed to throw its head back quickly, and will 
continue in this position for some time, even after the cough has 
produced the expulsion of the mucus.* If the disease remains un- 
subdued, the dyspnoea increases; the face shows the usual marks of 
impeded circulation ; the surface becomes cold ; the extremities some- 
times swell, and the child dies from suffocation. Very often, the 
sound of the voice and the cough is as shrill as in the croup, with 
which disease bronchitis is sometimes confounded. Dr. Hastings, in 
his very excellent work on the lungs, has given a concise account of 
a variety of acute bronchial inflammations, to which young children 
are peculiarly subject, which I have often had occasion to see. 
Although more dangerous, the symptoms are not of corresponding 
severity; in truth, it is a sub-acute inflammation of the bronchial 
membrane throughout the whole extent of both lungs. No severe 
symptoms are excited as long as expectoration continues free, and is 
discharged with ease ; but should the mucus by any accident increase, 
the cough at the same time ceasing, speedy death from suffocation 
inevitably follows, unless vomiting be excited, which seems to have 
the effect of emptying the air-passages of the secretion. Other cases 
take an unfavourable turn, by the inflammation becoming more ac- 
tive, from some accidental circumstance, such, perhaps, as exposure 
to cold. Cases of this sort are most common in spring and autumn. 
In the acute bronchial affections of children, there are often consider- 
able variations in the state of the breathing and the pulse — the 
latter depending in a great degree on the former. The breathing for 
several hours continues free and easy; afterwards it gradually be- 
comes less so; and at last great difficulty takes place suddenly, even 
so as to threaten immediate suffocation. These exacerbations appear 
to be owing to three circumstances; 1st, Collection of mucus in the 
bronchi; 2d, Increased circulation through the lungs; and lastly, 
Venous congestion. Children so affected soon fall into a comatose 
state ; the face, which for some days, perhaps, had been quite pallid, 
now becomes livid, or a dark circle shows itself round the mouih,and 
the child sinks in the manner already described. In some urgent cases, 
the fatal event takes place in sixty or seventy hours from the time 
alarm is taken; the majority of cases, however, are not so rapid, the 
course of the disease being from five to fifteen days ; but when it is 
protracted, other structures generally become involved, the inflam- 
mation spreading by contiguity; and the same happens in adults. 

* This position seems to facilitate the passage of air into the lungs. 



CHRONIC BRONCHITIS. 357 

In all affections of the lnngs, particularly in the acute, the bowels 
become constipated, and the evacuations fetid. 

The expectoration in bronchitis is at first scanty and. viscid, par- 
ticularly so in the most acute cases; by degrees it becomes more 
copious and less viscid, and, therefore, more easily expectorated, till 
at last it is discharged in considerable quantity, having the appear- 
ance of starch mixed with small bubbles of air, and occasionally 
streaked with a little blood, or is discharged in the form of pellets. 
If the case go on well, the expectoration gradually diminishes, and 
becomes slightly yellow in colour; the patient is troubled with the 
cough and expectoration in the morning only; at length they cease 
entirely. Sometimes, however, the acute disease runs into the 
chronic form, which is now to be described. 



CHRONIC BRONCHITIS. 

Like other chronic inflammations, this affection sometimes suc- 
ceeds to an acute attack; — sometimes, however, it takes place as a 
slow and insidious inflammation of the bronchial membrane. This 
form of the disease may affect individuals of all ages; but it is most 
frequently met with in old people, and those who, by occupation, 
are exposed to the inhalation of dust. It sometimes succeeds also 
to the eruptive fevers; and frequently coexists with diseases of the 
heart. 

It is occasionally mistaken for phthisis pulmonalis; and is one of 
the morbid conditions of the organs within the chest, which give rise 
to the symptoms denominated asthma; and is likewise a frequent 
cause of dropsical affections. 

When the disease succeeds to acute bronchitis, the fever declines, 
but the pnlse for some time continues frequent; the cough and diffi- 
culty of breathing continue, but they are always relieved for a con- 
siderable time alter free expectoration. The patient still has night 
Brbations and disturbed sleep, which, however, gradually decline 
with lip- disease. The expectoration still copious, becomes opaque, 
yellow; sometimes puriform, and lias occasionally a greenish hue; at 
last it diminishes in quantity. The appetite returns; and although 
weakened by copious night perspirations, and which take place 
during the day upon making the least exertion, the patient is sensi- 
ble of gaining some strength. Gradually all these symptoms cease, 
and Borne individuals appear to undergo a perfect cure ; but in general 
they :>re not s<> fortunate, for during the subsequent pari of their 
lives, exposure to the night air, an easterly wmd, or a humid atrao- 
gphere, occasions a renewed attack; and with many, the same eflect 
is produced by eating indigestible food, or by neglecting the bowels. 

Now and then, therefore, they become indisposed; the voice h unes 

ho irse •. the cough short and croupy, with more or less oppression in 
breathing, attended sometimes by febrile symptoms. In the chronic 
form "i the disease, ihe expectoration takes place in a much shorter 
tune t r. >ni the commencement "i the indisposition than in the acute; 

Sometimes in a lew hours: it is Viscid at fust, but soon becomes 



358 CHRONIC BRONCHITIS. 

copious, and the patient is relieved by the discharge. One attack 
leads to another, till at last the individual is always affected with 
some degree of dyspnoea— he is almost constantly coughing and 
spitting, and is unable to lie in the horizontal posture; he feels 
great difficulty in mounting a stair — and is said, in short, to have an 
habitual asthma. 

I have stated that Morgagni seems to have been well acquainted 
with the phenomena of chronic bronchitis. We are told, for instance, 
by Morgagni, that Valsalva examined the body of the Bishop of 
Imola, who was supposed to have died of phthisis, having had con- 
siderable expectoration before his death ; but he did not find tuber- 
cles, or any other disease, in the structure of the lungs. 

In the acute and chronic forms of bronchitis, cases now and then 
present themselves, in which the expectoration is very small in quan- 
tity, so as sometimes scarcely to be perceived, when the disease has 
been denominated Dry Catarrh and Dry Jisthma. 

Stethoscopic signs of acute and chronic bronchitis. — Percussion 
affords little information in any of the forms of bronchitis; but aus- 
cultation enables us to determine the stage and extent of the disease, 
even before the symptoms are completely formed. In the first stage 
of inflammation of the mucous membrane of the bronchi, it becomes 
somewhat swollen, probably from the increased quantity of blood in 
its vessels, and its surface dry; upon applying the ear to the chest, 
either with or without the cylinder, instead of hearing the natural 
soft murmur of respiration, a louder sound strikes the ear; sometimes 
like a snore, at other times sibilous, or resembling what may be called 
a somewhat harsh, brazen sound. It is more sonorous and flatter, 
according to Laennec, in proportion as the mucous membrane is 
swollen, and its surface dry ; and he states — « When so strong as to 
resemble the prolonged scrape of the bow on a large violoncello 
string, or the note of the wood-pigeon, there are usually redness and 
swelling at the bifurcation of some of the principal bronchia."* 

As the disease advances, it has been stated that wheezing takes 
place, which is produced by the passage of air through the diseased 
secretion in the bronchial tubes; this is called the mucous rale or 
rattle, which in many cases is so loud, as not only to be heard on 
entering the room, but to be felt by placing the hand upon the chest, 
which experiences a vibration during each inspiration and expira- 
tion. In some cases, we may find the respiration suspended in a 
portion of the lung for an hour or two, which becomes restored after 
a severe fit of coughing. In this case, percussion may be of some 
assistance to us. These occasional interruptions to respiration are 
owing to a plug of tenacious mucus or lymph closing up the entrance 
of a tube; or it may be completely filled with viscid matter. 

In chronic bronchitis, attended with expectoration, we have in 
some cases the same mucous rattle over the whole thorax. When 
there is no expectoration, then we hear pretty loud snoring, which is 
denominated the dry sonorous rattle; occasionally it resembles the 
cooing of a wood-pigeon ; and sometimes at the very top of the in- 
spiration, a sound is heard like the chirping of a bird. 

* Forbes's Translation, p. 67. 



CHRONIC BRONCHITIS. 359 

Occasionally, a prolonged hissing sound is perceived, flat or sharp, 
of greater or less intensity, called the dry sibi/ous rattle, which has 
a resemblance, also, to the chirping of birds. And sometimes a sound 
is heard, which Laennec has aptly compared to that which is "emit- 
ted by suddenly separating two portions of smoothed oil stone, or by 
the action of a small valve." In truth, it is what may be denomi- 
nated a clicking sound. Laennec states, that these sibilous sounds 
are probably owing to minute portions of very viscid mucus, ob- 
structing more or less completely the small bronchial ramifications, 
or to a local contraction of the small tubes, from thickening of their 
inner membrane. 

•Appearances on dissection, and pathological remarks. — On 
opening the thorax, we generally find that the lungs do not collapse 
from the pressure of the atmosphere, if the individual have died 
from suffocation in consequence of the engorgement of the bronchi 
with matter. In some cases, in which the cough has been severe, 
the surface of the lungs looks white, as if coated with a layer of 
coagulable lymph ; but on examining this appearance more closely, 
it is found to depend on an effusion of air beneath the pleura, form- 
ing that peculiar condition termed "emphysema." On opening the 
trachea, it will sometimes be found filled with matter; but, in gene- 
ral, it is merely coated with thick, viscid mucus, which, when wiped 
off, shows some degree of redness, increasing towards the bifurca- 
tion. The bronchial tubes are found more or less filled with matter, 
which is sometimes like mucus or pus; occasionally it has a mixed 
appearance, which is appropriately denominated muco-purnlent ; 
sometimes it is tinged with blood, and looks reddish. This secretion 
is found occasionally even in the air-cells, distending them, giving a 
uniform granular appearance to the whole of the part affected; and 
there can be no doubt that this is one way in which tubercular for- 
mations take place in the lungs. Upon washing away the puriform 
matter, the mucous membrane itself will be sometimes found in- 
tensely ifil; at others, of a dark red, like lees of wine; the disco- 
loration increases in the course of the ramifications. The texture 
of tin; membrane is observed to be thickened, more especially in 
chronic inflammation. Ulcerations are frequently seen at the great 
bifurcation, rarely lower down. The pulmonary substance will be 
found more Of less gorged with blood, and sometimes oedematous. 
These are the ordinary appearances observed in bronchitis; the fol- 
lowing are to be regarded as accidental. False membrane is -some- 
times found in the trachea, the s;nne as in croup ; the lungs are seen 
in different stages of inflammation, from active sanguineous engorge- 
ment to complete disorganization \ pleuritic effusions are also some- 
times found, and enlargement of the bronchial glands. In the brain 
we frequently see marks of impeded eirenlati sometimes inllam- 

inatiou In the abdomen, the lister is sometimes fooud gorged or 
altered in structure, and the muCDBS membrane of the stomach and 
bowels shows various degrees of Waecohwity, and even ulceration. 

These appearances in the liver and bowels, are, m all probability, 
owing to long-continued impeded circulation through the lungs, and 
ised condition of the blood. 



360 CHRONIC BRONCHITIS. 

In chronic bronchitis, we sometimes find considerable dilatation 
of the larger tubes, which is, perhaps, chiefly brought about by long- 
continued distension — a remarkable case of which once occurred to 
me. In this instance, I declared that there was a cavern in the supe- 
rior lobe of the right lung, which, upon dissection, turned out not to 
be the case, but there was an immense dilatation of the bronchial 
tube; thus mistaking bronchophony for pectoriloquy. Another case 
occurred to Dr. Alison, in which the dilatation was great, and the 
tubes affected numerous. A portion of the lungs is in my museum, 
and a delineation is given by Mr. Spittal, in an excellent work on 
auscultation, to which I can with confidence recommend my readers. 
I have likewise two preparations, exhibiting numerous portions of 
false membrane, like the ramifications of an artery into very minute 
branches, which were formed in the bronchial tubes of a boy who 
died of chronic bronchitis. 

In making post-mortem examinations, with a view of discovering 
the nature and seat of bronchitis, these accidental morbid alterations 
of structure should be kept in mind, along with the symptoms and 
progress of the case ; because, although they may form the most pro- 
minent appearances on dissection, and are no doubt in many instances 
the cause of death, yet they are only to be regarded as the effects of 
the original disease. Nay, sometimes an individual labouring under 
acute or chronic bronchitis, may have expectorated freely, immedi- 
ately before death, when we shall find little or no effusion in the 
bronchial tubes, and sometimes very little redness. It is proper to 
state also, that notwithstanding the attention which has been paid, of 
late years, to the pathology of the lungs, there is still some ambiguity 
connected with this subject, evinced by the fact, that dividing the 
pueumogastric nerves in animals produces dyspnoea, change of voice, 
and effusion into the air-passages. 

Of all the symptoms, wheezing is the one which may be said to be 
peculiar to bronchitis; cough and dyspnoea, it has already been 
shown, are common to all diseased conditions of the lungs, and not 
of the lungs only, but of other organs. Some assert that the wheez- 
ing is owing to spasm, but this is not the case, for we find that it is 
greatest before expectoration takes place, the patient afterwards 
being pretty free from it till a fresh secretion collects in the air-pas- 
pages. Dyspnoea has also by some been attributed to spasm. Reis- 
seissen thinks he has ascertained the existence of circular fibres in 
the ramifications of the bronchi, commencing at the point where the 
cartilaginous circles terminate. Laennec supposes that he has also 
proved the existence of these fibres upon branches of the bronchi, of 
less than a line in diameter; and therefore concludes, that spasmodic 
contraction of these fibres occasionally produces dyspnoea. I am far 
from admitting this structure in the present state of our knowledge; 
but even if it were so, it is of little consequence, when there is an 
increased quantity of the mucus in the tubes themselves, offering a 
sufficient mechanical cause for the phenomenon itself, and for the 
exacerbations and remissions, which are so frequently observed in 
all the forms of bronchitis. Whatever consequence may be attributed 
to such a structure, in accounting for the symptoms in some cases of 






ACUTE BRONCHITIS. 361 

asthma, it is of little practical importance in acute or chronic bron- 
chial inflammation. 

It has been already shown how the brain becomes affected during 
the course of bronchitis, when severe pain in the forehead is often 
remarked. Some suppose this is owing to inflammation of the 
membrane lining the frontal sinuses; but this is not the case, for if it 
were, this symptom would be most severe when patients are affected 
with what is called "a cold in the head;" besides which, it is a 
different kind of pain. That which proceeds from the irritated state 
of the membrane in the frontal sinuses is pungent, producing a flow 
of tears, exactly as when we smell volatile salts. The lividity of 
the face and lips, and mucous membrane of the mouth, is owing 
to the want of the usual changes which take place on the blood in 
the lungs. 

Treatment of acute bronchitis. — This depends exactly upon the 
period of the disease, the extent of the morbid action, the state of 
the cough, the expectoration, and the previous health of the patient. 
Bleeding is certainly not necessary in every case of bronchitis which 
comes before us, particularly in one that is slight, and confined to a 
small part of the lung: but if the whole lung be affected, and more 
especially, when both organs are implicated, bleeding is to be had 
recourse to early and decidedly. It is a very doubtful remedy when 
the second stage is far advanced, and highly injurious in the last. I 
know no disease more under management by any remedy, than 
bronchitis is by bleeding, if performed in the first stage, or during the 
first part of the second; and there is no case in which the stethoscope 
is more useful, for without it, this disease may advance through the 
first stage before it is detected by the ordinary means of investiga- 
tion. Many assert that bronchial inflammation will run through a 
certain course in spite of every remedy; and so it will, if the inflam- 
matory stage is nearly over before, discovered, or if bleeding be not 
used in a decided manner. Although late bleedings are to be espe- 
cially condemned in this disease, yet cases do occur, where the lungs 
become suddenly congested with blood, in which a well-timed vene- 
section is of signal service. 

In the first stage of bronchitis, when both lungs are extensively 
affected, one bleeding will in general suffice, and we need not be 
afraid to carry it nearly to syncope, as long as the air-passages are 
in-'' from mucus; hut after it has collected in considerable quantity, 
and I speak more particularly with respect to double bronchitis, 
Btldden death may be the consequence, by robbing the patient of that 

strength which is required in coughing to produce expulsion. In 
bronchitis, we can scarcely ever determine the necessity or the pro- 
priety of bleeding by the ordinary signs, because, in some cases, the 

disease may be very extensive without violent symptoms; m others, 

it may be very slight, am! the symptoms very severe, owing, perhaps, 

to a disordered state of the stomach and bowels, or to some other 

perhaps Blighi cause ; ami it i> of great consequence to know when to 

t from further depletion. 

Cullen, in the 38lst paragraph, states, that "in case the fever, 

catarrhal and pneumonic symptoms, are immediately considerable, a 

31 



362 ACUTE BRONCHITIS. 

blood-letting will certainly be proper and necessary; but where these 
symptoms are moderate, a blood-letting will hardly be requisite; and, 
when an effusion is to be feared, the repetition of blood-letting may 
prove extremely hurtful." Which statement sufficiently proves that 
he must have practised with great uncertainty. We are to decline 
bleeding, not because we are afraid of producing effusion, but 
when we know that it already exists in considerable quantity in both 
lungs. 

Leeching or cupping is very seldom serviceable in this disease;* 
but iii children who are too young to be bled in the arm, leeches are 
to be applied ; and we have sometimes great difficulty in determining 
the number— suffice it to say that it is better to apply few when in 
doubt upon the subject, and to repeat the operation in a short time. 
If consulted early, we can make a near approach to the effects pro- 
duced by general bleeding, by applying a considerable number of 
leeches at one time, and stopping the discharge soon, so as not to 
allow the body to be slowly drained of blood ; but even in children, 
it is far better to draw blood from a vein, when it is practicable. I 
speak from the result of considerable experience. 

Next in point of importance to blood-letting, in pulmonary inflam- 
mation, stands antimony, as a contra-stimulant; this was well known, 
and constantly acted upon by Cullen, Fordyce and others, in the 
last century, and it surprises me greatly to hear this practice attri- 
buted to Italian and French physicians. Digitalis is of little use, 
unless given in considerably larger doses than are generally recom- 
mended ; but it is a dangerous remedy when the air-passages are 
much loaded. Colchicum has been highly recommended in this dis- 
ease by a friend, who states that its effect on the pulse and the other 
symptoms are sometimes quite remarkable. Emetics are very ser- 
viceable in the first stage; and are absolutely necessary in the last, 
in order to clear the air-passages when the cough fails to do so ; and 
are more particularly serviceable in childhood and infancy. 

Purgatives were at one time thought highly injurious in all in- 
flammatory affections pf the lungs, but upon erroneous pathological 
views. 

Expectorants and diaphoretics are more injurious than beneficial, 
except, perhaps, in chronic affections; and I have often had to regret 
the loss of much valuable time by trusting to their action. 

Opiates are, perhaps, more frequently injudiciously administered 
in inflammatory affections of the lungs, than in any other class of 
diseases. They are sometimes exceedingly serviceable, but in the 
great proportion of cases they are injurious, and in some instances 
are the cause of death. These observations apply more particularly 
to the disease under consideration. Nothing can be more detri- 
mental than opiates, in the last part of the second, and during the 
whole of the third stage of bronchitis, when the patient's life depends 
upon the continuation of the cough and the expectoration ; many 
an individual has perished in consequence of a three hours' sleep. 

[* Experience has led the physicians of the United States to the converse of this 
opinion; after general bleeding, local bleeding, especially by cups, is justly esteemed 
one of our most efficient resources in bronchitis.] 



ACUTE BRONCHITIS. 363 

But opiates are sometimes useful, in the first stage, after the violence 
of the disease has been reduced by the lancet; they subdue irritation, 
the continuance of which would, perhaps, lead to a relapse. In the 
last stage also, they are occasionally serviceable when there is little 
or no secretion in the air-passages, and when there is considerable 
irritation and a violent cough, which, if not mitigated, keep the 
patient from sleep, and wear him out. 

Contra-irritation is another powerful remedy in pulmonary inflam- 
mations; but experienced practitioners agree in condemning the too 
early application of blisters, which, in truth, ought to be employed 
oftener as a measure of safety than of necessity. In acute cases, we 
cannot wait for the contra-irritation produced by antimonial oint- 
ment; a blister should, therefore, be applied. 

Attention, during the whole period of the disease, should be paid 
to the temperature of the extremities; and a warm bath has some- 
times excellent effects in removing irritation and promoting the com- 
fort of (he patient. 

The regimen should be strictly antiphlogistic ; but stimulants are 
occasionally very serviceable in the last stage. The patient is some- 
times so weak and languid that he cannot make any voluntary 
efforts to cough, upon which, perhaps, his life depends. In such a 
case, a stimulant, frequently repeated, occasionally snatches an indi- 
vidual from the grave. It is difficult, however, to account for the 
stimulating treatment practised by Laennec, who, in recommending 
the use of the spirituous preparations, such as warm wine, burnt 
brandy, and punch, says — "This plan is unquestionably eminently 
successful in a vast number of cases. By it we frequently observe 
a cold which seemed to threaten great severity, cured all at once in 
the course of a single night" — (page 70.) But he observes, in the sub- 
sequent page, that this plan is most successful in the very onset of 
catarrh; and that it is much less so after the supervention of the loose 
expectoration. Whether this be owing to difference of climate or 
constitution, it is difficult to determine; but that the disease of which 
I have been treating, demands very different means on this side of 
tin; channel, I need not waste time to prove. 

In the treatment of acute and sub-acute pulmonary inflamma- 
. u is necessary to keep tin; patient qoiel in bed — every exer- 
tion mUSl he avoided j the exercise of the voice is also injurious; and 
during recovery, it is essential ( ° attend to the diet and clothing; the 
bowels are still to be regulated; and bitters are sometimes service- 
able. Ill severe rases, 1 hold it to lie of :u I va 1 1 ta ge to persevere for 

several weeks in supporting an eruption on the surface of the chest 
by tartrate of antimonial ointment, or croton nil, or the frequent appli- 
cation of must-nil plasters, or stimulating embrocations. Change of 

air, however serviceable il may be ill some chronic, cases, is often 

very detrimental in those now under consideration ; unless it be from 
the smoky air of London to the country, and even then il is always 
doubtful whether the patient may be benefited or injured by the 

chang 

Treat mtnl <>J chronic bronchitis. — In the treatment of ibis form 

of the disease, we 1 1 1 1 1 s-t avei keep in view, that patients are in dan- 



364 CHRONIC BRONCHITIS. 

ger of sudden attacks of acute inflammation and vascular accumu- 
lations, which may terminate fatally; or the substance of the lungs 
may become affected, by the diseased action spreading by contiguity ; 
lastly, oedema of the lungs may take place, which is not an uncom- 
mon consequence of this affection. 

General bleeding is rarely necessary, except in the following cir- 
cumstances, viz.: the occurrence of acute inflammation, sudden con- 
gestion of the lungs, or dropsy depending on bronchitis. Contra- 
stimulants are almost as rarely necessary as general bleeding. The 
frequent exhibition of emetics cannot be loo highly extolled ; they 
appear to be most serviceable at night, immediately before the usual 
hour of rest, and in the morning, particularly after a tolerably long 
sleep : their modus operandi has been already explained. Constant 
attention to the bowels is of the greatest utility, and the occasional 
use of the warm bath is serviceable when the skin is dry and harsh. 
Expectorants appear to be somewhat serviceable, and the best is 
squills. But 1 have seen expectorants used for a considerable time 
without any benefit, till after the application of a blister, or the use 
of the inhaler, when the discharge has become free and easy. Of all 
the remedies hitherto recommended for the cure of chronic bron- 
chitis, the best is long-continued contra-irritation by a succession of 
blisters, and particularly by the application of antimonial ointment, 
or croton oil. [When the disease is confined to one lung, and espe- 
cially to a part only of one lung, the most effectual counter-irritant 
is an issue formed by the paste of caustic potash and soap.] 

The balsams have been strongly recommended for their peculiar 
efficacy in inflammation of the mucous membrane, more especially 
that of the lungs. Dr. Armstrong has spoken very favourably of 
them in his work on Scarlatina, &c. ; but I have no doubt, subse- 
quent experience modified his opinions upon this subject. I have 
tried the copaiva in many cases in practice, without being able to 
discover its efficacy. Tar-vapour has been recommended as a sove- 
reign remedy in phthisis, and there can be no doubt it has been 
beneficial ; but the cases in which service may be expected, are those 
of uncomplicated chronic bronchitis. [Much of the disappointment 
which has arisen from the use of tar-vapour, has been owing to its 
imperfect preparation. The following method, which I have derived 
from Sir Alexander Crichtoti, is the best that has come to my know- 
ledge. Add an ounce of common potash to every pound of tar, in 
order that the latter may be deprived of its pyroligneous acid. The 
two ingredients being well mixed, should be first boiled together for 
fifteen minutes in the open air, in order to disengage any impurities, 
and then be kept at a very gentle simmer in the room of the patient. 
This is readily effected by placing the ingredients in an iron vessel, 
and applying a spirit lamp. In this way not only a chamber, but 
an entire house, is speedily pervaded with a most agreeable vapour, 
which, even though it may at first excite some cough, has, in many 
cases, the happiest effect. 

Frankincense and common rosin are often burned in the apart- 
ments of bronchilic patients for the same purpose as tar; but the 
empyreumatic smoke which they throw off is sometimes an ob- 



[CHRONIC BRONCHITIS.] 365 

jection to their use; yet they sometimes act promptly in alleviating 
the irritation. The vapour of chlorine, so much lauded by some 
practitioners, has uniformly aggravated the cases in which I have 
tried it.] 

Good effects have frequently been produced by the tinctura lyttcc, 
but exhibited in doses two or three times greater than those com- 
monly used. 

[The preparations of iodine should not be overlooked. In dry 
catarrh, whether of the acute or chronic variety, they act most hap- 
pily in exciting the mucous secretion; but they cannot be safely 
interposed until the active inflammatory symptoms are subdued. In 
a future part of this work, when treating of phthisis, we propose to 
examine more minutely into the use of iodine in pulmonary affec- 
tions, and therefore defer their consideration for the present. 

My experience in the use of the balsams differs much from that of 
the author; for 1 have, on many occasions, been satisfied of their 
utility. The balsam of copaiba is, perhaps, the best; and to counteract 
its disagreeable taste, it should be given in pill. The syrup of tolu, 
though a weak preparation, appears also to act favourably in common 
with the other balsams, in allaying irritation of the mucous mem- 
brane, and may be advantageously used to suspend and assist other 
expectorant medicines.* 

The several preparations of lobelia have also a decided virtue 
of the same kind. It is best given in tincture with tolu and lauda- 
num ; but its use requires caution on account of its tendency to pro- 
duce excessive vomiting. 

Every practitioner must have remarked, that, although the most 
irritating and intractable symptom of bronchitis is a dry cough, 
which we seek to relieve by inducing expectoration, yet there are 
other cases in which the secretion of mucus is in excess, filling the 
bronchial tubes and requiring continual debilitating efforts for its 
rejection. To meet this contingency, various plans have been de- 
wed, and particularly the alterative course with iodine, and resinous 
inhalation. But Dr. Henderson, of Edinburgh, has recomniendedfor 
this purposes preparation of the acetate of lead, which, in his hands, 
DM been entirely successful. He directs one or two grains with 
I une extract of hyoscyamus, and a grain of squills, three times a day. 
Dry coughs air w<;ll known to terminate in expectoration, which is 
a most favourable result, and one which tends to cure; but in the 
present instance, our remarks apply solely to excessive mucous or 
muco-purulent expectoration of some continuance, in which the 
inflammatory or Febrile symptoms have in great measure or entirely 
disappeared.] 

If change of air be bad recourse to, a warm situation should be 

it, with a dry sandy soil ; patients should avoid exposing them- 

night, or during cold damp weather, particularly in this 

country when tii<' wind blows from the cast. Warm clothing is 

highly necessary | tun it is important that medical men should prevent 

the patient from being tOO much loaded ; and the best way to accom- 

• v A 9i as 'ji.j 

31* 



366 INFLAMMATION OF THE LARYNX. 

plish this is, by recommending a leathern jacket and drawers, and to 
forbid a great coat, particularly if he be allowed to take walking exer- 
cise. I must refer the reader to Dr. Forbes's translation of Laen- 
nec's work for much valuable information on the subject of bronchial 
disease, and to the notes of the accomplished and experienced trans- 
lator also, who has conferred a great boon upon British practitioners. 



LARYNGITIS. INFLAMMATION OP THE LARYNX. 

This disease has a very close analogy to croup ; which, indeed, sel- 
dom exists without extending to the membrane lining the larynx; 
but as the inflammation is sometimes entirely confined to the latter 
organ, it is necessary to give a separate description of each disease. 

Inflammation of the larynx is a common cause of death in small- 
pox and scarlatina, and it sometimes follows measles. When this 
disease occurs in the acute form, it is known by a painful sense of 
constriction in the throat, which is increased by pressing the larynx; 
speaking aggravates the pain, as does swallowing; the voice is hoarse; 
the breathing soon becomes laborious and shrill during the act of 
inspiration; there are considerable heat of skin, thirst, rapid pulse, and 
great anxiety. On looking into the throat, the fauces frequently look 
swollen and turgid, and of a dark red colour, or coated with lymph ; 
but this affection of the throatis not peculiar to laryngitis, as the inflam- 
mation may be entirely confined to the larynx. In some cases, the 
epiglottis is involved, which renders the motion of the tongue painful. 
The patient is constantly hawking in order to clear the air-passages, 
and occasionally spits up a small quantity of thick tenacious phlegm. 
As the disease advances, the face becomes swollen and turgid ; it has 
frequently a livid appearance, and life is quickly destroyed by suffo- 
cation. Convulsions occasionally precede death. This disease some- 
times runs its course in from thirty-six to forty-eight hours. 

A chronic form of inflammation of the larynx, although described 
by some as being of more common occurrence than the acute, is, I 
apprehend, less frequently met with: the mistake having arisen from 
its being confounded with the disease described by Bayle, under the 
name of oedema glottidis. [Yet the latter condition is almost inva- 
riably a consequence of inflammation, which, extending from the 
mucous membrane, involves the cellular coat. Effusion then takes 
place, forming one of the most suffering and intractable forms of 
laryngeal disease.] That chronic inflammation, however, does take 
place, we have very good proof, from the ulcerations which are 
found in the larynx, and also round the glottis, which even destroys 
portions of the cartilages. In the chronic disease, particularly when 
attended with ulceration, there is pain ascribed to the part affected, 
great difficulty and pain in swallowing, hoarse voice and dyspnoea, 
with violent fits of coughing; the patient passes distressing feverish 
nights, and expectorates a scanty, sometimes sanious-looking matter, 
which has occasionally an offensive odour. This form of the dis- 
ease sometimes accompanies phthisis pulmonalis; whether it does so 



[INFLAMMATION OF THE LARYNX.] 567 

or not, the patient becomes emaciated, and dies with the usual symp- 
toms of hectic fever. 

On dissection, in the acute disease, the mucous membrane is found 
vascular, thickened, and rough from minute ulcerations, or it is co- 
vered with a thick exudation of lymph. 

[In other instances the ulcers are large, dark-coloured, and even in 
a state of sphacelus. I have observed that when the patient's voice 
has been reduced to a whisper, the vocal ligaments have been gene- 
rally more or less involved in the ulceration. 

Chronic inflammation and ulceration are more frequent in the tra- 
chea than in the larynx, producing a fearful destruction of parts. I 
have seen the tracheal cartilages eaten through by ulceration; and 
cases are recorded in which the purulent matter has formed pouch- 
like abscesses in the neck. 

In these cases the erosion, of course, perforates all the coats of the 
larynx ; whence the occurrence of fistula at the anterior angle of the 
thyroid cartilage. 

The disease called, in the nosological systems, laryngeal phthisis, 
is a chronic inflammation and ulceration of the mucous membrane 
of this part, and by long continuance produces nearly all the exterior 
symptoms of tubercular consumption. It is most generally, how- 
ever, one of the complications or sequelae of the latter disease; yet, 
though generally a consequence, it is sometimes also a cause; the 
larynx being the primary seat of the irritation, which is subsequently 
propagated to the lungs themselves. 

If any disease calls for active treatment, it is acute laryngitis. The 
extreme distress of the patient demands immediate interposition, 
without which we have also to dread the several chronic conditions 
which become more or less intractable, — ulceration, aphonia, oedema, 
&c. In strong constitutions and with an active pulse, bleeding is 
our principal dependence; and if relief be not speedily obtained, 
free leeching Bhould be resorted to without delay. Free doses of 
calomel tend to relax and unlock, as it were, the dry and tumid mn- 
membrane; but there are cases in winch tins should be pre- 
• I by emetics, among which tartrate of antimony is to be pre- 
ferred, because its action is more prolonged. There is also great ad- 
vantage, after leeching, (and in the place of it, if leeches cannot be 
had,] in fomentations to the trachea and neck by means of hot cloths 
frequently renewed; and these should be followed by warm flax 
teed poultices. Hot pedrluvia, long continued, are highly servicea- 
ble; and a general warm bath is yet better. After the acute symp- 
toms are mitigated, blisters become available. They may be applied 
10 the back OI the neck, or to the trachea itself, taking care to place 
them mi us lateral Btirface. The most efficient modi! is to make the 
application tonne Bide only, allow vesication to become complete, 

dress the blister wild simple ointment, and let it heal Up. Then make 
a like application to the Opposite side of the larynx; and by this i le 

nstanl drain and counter-irritation may be kept up without much 
inconvenience. 
Inhalation sometimes gives great relief in laryngitia I have 

found few things to answer belter than the fumes from hot water. 



368 CROUP. 

poured on hops or chamomile flowers ; and the simple vapour of hot 
water itself tends to relax the inflamed membrane, and conduces to 
expectoration. 

Some other remedies, together with the operation called tracheo- 
tomy, will be considered in the next chapter, on Croup] 

The treatment of chronic inflammation consists in close confine- 
ment to one apartment, strict attention to diet and the bowels, and 
silence on the part of the patient. Frequent, almost daily applica- 
tion of leeches to the proper region, and a repetition of blisters to 
the back of the neck; tar, and other vapours. have been strongly re- 
commended. When ulceration exists in the larynx, the case may be 
considered almost hopeless. Still it is our duty to do something for 
the patient. In this case the application of caustic has been re- 
commended, and, it is said, often practised ; but it is to be doubted 
whether a stick of caustic could be forced into the larynx without 
producing sudden death. Mons. Joubert, of Paris, has been very 
successful in curing ulcerations in the throat, and they say, in the 
larynx likewise, by the application of a saturated solution of oxy- 
muriate of mercury in pure nitro-muriatic acid. 



TRACHEITIS. CYNANCHE TRACHEALIS. CROUP. 

This disease is of frequent occurrence among children residing in 
damp, bleak situations, particularly on the sea-coast. It consists of 
an inflammation of the lining membrane of the trachea, and is often 
connected with bronchitis and laryngitis, the one running into the 
other, so much so, that they frequently cannot be distinguished. It 
is scarcely a hundred years since this disease was first recognized, 
but the first good description was given by the late Dr. Home. It is 
rather curious that croup is a disease almost peculiar to infancy and 
childhood, while inflammation of the larynx and bronchial tubes 
occurs at all ages. Although there are some instances of croup af- 
fecting adults,* yet it is rare to see it after 12 years of age. One at- 
tack predisposes to another; but as age advances, this susceptibility 
goes off. It is more frequently met with on the sea-coast than in 
inland districts, and in the neighbourhood of wet, marshy lands than 
in dry situations: thus it appears to be more frequent in Leith than 
in Edinburgh, notwithstanding the high and exposed situation of the 
latter. 

Dr. James Hamilton, jun., has stated, but perhaps inadvertently, 
that croup is a common disease in certain parts of Edinburgh. Above 
three thousand people were attended annually by my pupils for 
several years, and out of more than eighteen thousand patients we 
have not had above twelve cases of croup; but I have frequently 
been asked to attend dissections of children who were supposed to 
have died of croup, which proved, on examination, to be bronchitis. 

* It would appear that General Washington, the liberator of America, and Jose- 
phine Bonaparte, both died of this affection. The last fact is stated by Eretonneau, 
(at page 65,) on the authority of Beclard, who discovered the disease when employed 
in embalming the body. 



CROUP. 369 

Croup has been divided into three species, viz.: the acute, chronic, 
and spasmodic. Under this last head, I shall take an opportunity of 
noticing the affection already mentioned, as first described by Bayle 
in the year 1819. 

Phenomena. — It usually commences, like a catarrh, the symptoms 
being more or less severe, with some degree of fever, preceded by 
chilliness; the voice soon becomes hoarse; febrile symptoms increase; 
and in a day or two, the breathing is more and more impeded, par- 
ticularly during inspiration ; at last, the respiration becomes stridu- 
lous, and the voice shrill ; a harsh, dry cough exists from the begin- 
ning, and when there is any expectoration, it has more or less of a 
muco-purulent appearance; sometimes small masses of lymph are 
discharged, which occasionally resemble portions of false membrane. 
As the disease advances, the expression of countenance becomes 
more anxious ; the lips and cheeks have a swollen, livid appearance, 
alternating, perhaps, with a deadly paleness. The pulse is frequent and 
small, and occasionally intermits. There are prostration of strength, 
and restlessness; although the surface of the body be, generally 
speaking, hot, the extremities are frequently cold; at last, the body 
is covered with a cold, clammy sweat, and the child dies of suffoca- 
tion. On looking into the throat, the fauces are sometimes found 
inflamed and swollen; but this is not a necessary part of the disease; 
it merely shows that the inflammation is extensive. Many cases of 
croup, however, which I have seen, appear to have been produced 
by the extension of inflammation from the throat into the air-pas- 
B iges. This was the case in the disease described by M. Brelonneau, 
and to which he gave the name of Diphtherite.* The course of the 
disease is various; sometimes children are cut off early from asphyxia, 
hut in general it lasts from two to four days. In chronic affections of 
the trachea, the symptoms are less violent and urgent, but having, 
npon tin; whole, pretty much the same character, viz.: dyspnoea, 
shrill voice, and stridulous breathing. This is probably the affection 
that Dr. Warren has called "bronchial polypus," and which he has 
described in the I si volume of the Transactions of the College of 
Physicians. 

hi be no doubt that cold and moisture produce 
tip.- disease, and th it Bometimes, from peculiar circumstances, a great 
many cases have occurred in the same district. The most remark- 
able epidemic appears to have been that which took place at Tours 
some years ago, and which is described by M. Bretobneau, during 
winch one I, Mildred and fifty individuals died. It affected adults as 

well as children, and was particularly severe in a French legion, 

quartered in the district. This author supposes diphtherite to be con- 
tagious; i, m whether contagious 01 epidemic, it is impossible to de- 
termine, it sometimes succeeds to bronchitis, ami also to severe 
inflammation of the fauces. 

Appearances "a dissection. — On opening the trachea, false mem- 
brane is found lining the organ in various states; sometimes it is soft 
and diffluent; Bometimes partial; at others extending beyond tho 

♦ Trail* de la Diphtherite, pai i\ Breiooneao, 1886. 



370 CROUP. 

bifurcation. Sometimes it is found of very considerable thickness 
and firmness, of a tubular form, corresponding exactly with the canal 
which it covers, and extending an inch or two into the bronchi ; on 
some occasions, the first divisions of the tubes are as completely lined 
as the trachea. Frequently the larynx is similarly affected, but I 
have never seen a complete tube in this situation. [These mem- 
branes, according to Andral, present no trace of organization, not- 
withstanding that some authors insist that they have traced blood- 
vessels passing between the false membrane and the subjacent mu- 
cous coat. These filaments, however, are merely prolongations of the 
false membrane itself, extending into the follicles; neither should we 
be deceived, adds M. Andral, by the red spots which are sometimes 
scattered over the surface of the membrane, as they almost invariably 
result from an oozing of blood from the mucous coat of the trachea. 
Still there can be no reason why these false membranes may not 
become organized; but this change requires a longer continuance of 
disease than generally happens in the acute form of croup.] 

On some occasions, bronchitis coexists in one lung, or in both, which 
must always be kept in view, when considering the probability of 
affording relief by the operation of brouchotomy. I have seen the 
lungs inflamed in various degrees, and almost always considerable 
portions are in a state of engorgement, owing, perhaps, to the me- 
chanical impediment to respiration. 

In M. Bretonneau's numerous dissections, false membrane was 
found extending from the tonsils down to the air-passages, and some- 
times even into the oesophagus. 

Pathological remarks. — Since the publication of Dr. Cheyne's 
beautiful illustrations of croup, no doubt has existed that the false 
membrane is the product of severe inflammatory action of the mu- 
cous surface. 

A great deal too much has been attributed to spasm in this disease. 
Cullen, for instance, assigns more danger to spasmodic action than 
to the exudation of lymph. In the 327th paragraph, he says, "The 
peculiar and troublesome circumstance of the disease, seems to 
consist in a spasm of the muscles of the glottis, ivhich, by inducing 
a suffocation, prevents the common consequences of inflamma- 
tion;" and again, in the 329th, "When the disease ends fatally, it 
is by a suffocation, seemingly, as toe have said, depending upon a 
spasm affecting the glottis; but sometimes, probably , depending 
upon a quantity of matter filling the bronchise." At the same 
time, he attributed the febrile symptoms to a corresponding spasm 
on the surface; in fact, he was fond of riding his spasmodic hobby, 
and being unacquainted with pathological investigations, his great 
mind was frequently turned out of the proper path of inquiry. 

Spasm may certainly exist in this disease ; but there is sufficient 
to account for the symptoms without having recourse to spasm as a 
cause. We have at first slight difficulty of breathing, from the in- 
creased vascularity and distension of the vessels of the mucous 
membrane producing swelling, and consequently some diminution 
in the calibre of the air-tube ; subsequently, from a greater or less 
degree of congestion of the lungs ; and lastly, from the exudation. 



CROUP. 371 

Death is sometimes produced by asphyxia early in the disease, by 
congestion of the lungs, and by the inflammation being peculiarly 
severe at the rima of the glottis, occasioning such a degree of swell- 
ing as to prevent inspiration ; and children often die during the act 
of crowing. 

Treatment.* — This is a disease of all others which requires 
promptness of decision, and activity in practice; for if the false 
membrane be allowed to form, not above one case in a hundred can 
be saved. The worst cases are those in which a sore throat has 
been neglected, and the inflammation has spread into the windpipe ; 
or those in which patients have laboured under bronchitic symptoms 
for a week, or perhaps more, before the disease has affected the 
trachea and larynx, in which circumstances, a recovery is rather to 
be considered as an escape than as an event to be expected. Very 
opposite opinions exist respecting the treatment ; some trust, perhaps 
too much, to bleeding and blistering, to the neglect of other means; 
and there are others who assert that bleeding is injurious. I shall 
first state the practice which I have found to be successful, and after- 
wards that which has been recommended by others. 

If consulted early, there can be no doubt of the propriety, nay, 
the necessity of drawing blood ; if, by opening a vein, so much the 
better, because we can thereby make an instantaneous impression 
upon the disease, and upon the system, by diminishing the quantity 
of blood, altering the determination, and unloading the lungs. How- 
ever young the child, if above eighteen months or two years old, I 
would recommend this practice from experience; but only when the 
child has been previously healthy, and we are satisfied that there is 
no considerable effusion into the ramifications of the bronchi, and 
that the false membrane is not already formed in the trachea; other- 
wise death will frequently be the consequence. This happened in 
the case related in the ISth observation of Jiretonneau's work; the 
patient was bled on the sixtli day of a severe disease, and died the 
MOM night. Among other appearances found in the dissection of 
this case, were the following: — " The false membrane lined the 
larynx, the trachea, and extended deeply into the air-passages, even 
to the fourth subdivision of the bronchi of the right side, and the 
last ramifications ou t he left." [The late Dr. Dewees had great 
experience in croup at a time when, from the exclusive use of wood 
fires, and the consequent variable temperature of our houses, the 
disease was much more common than it now is. It was his uniform 
practice, in the first stage of croup, to inflame the parts over the 
throat by spirits of turpentiue, hartshorn, or mustard. If the first 
application did noi subdue the koarseneM,i\ was repeated as soon 
ai the rubefacient effect BUbsjded ; for he carefully avoided carrying 
th»-sc rubefacients to the extent of blistering the Bkin.t These reme- 
«li's, conjoined with an emetic, and resorted to at the orwei of the 
disease, and followed by a free dose of calomel, will be effectual in 
the great majority of cases, as my OWIl experience can testily.] 
Leeches are to be applied m numbers corresponding to the age, 

• I are equally applicable to inflammation of the larynx. 

[t un of Children, p. ]ffl.\ 



S72 CROUP. 

strength of constitution of the patient, and period of the disease ; and 
should be placed along the course of the windpipe, or top of the 
sternum; they should be repeated according to circumstances. But 
it can be of no use to draw blood even in this manner, if a sufficient 
number of leeches be not used, and reapplied at sufficiently short 
intervals, or if not employed till the false membrane be already 
formed. In the case which forms Bretonneau's 17th observation, it 
will be found that a child of twenty-seven months old, was seized 
on the 4th December with a slight cold, and altered tone of voice. 
During the 5th and 6th it became worse, and on the 7th we are 
told that three leeches were applied to the neck, and a little ipecacu- 
anha was prescribed, which was continued on the 8th and 9th without 
the leeches; the child died on the 12th. It is no wonder, then, that 
this author should condemn depletion, this being the way in which it 
was employed. 

If general blood-letting be used, one operation ought to be suffi- 
cient, and we must subsequently trust to the application of leeches. 

Emetics are to be administered, more especially at the beginning 
of the disease, and when it is complicated with bronchitic effusion. 
In the commencement, the best emetics are the antimonial, prepared 
by dissolving two grains of the tartrate of antimony in two ounces 
of water, a teaspoonful of which is to be given every five or ten 
minutes, till the full effect be produced. In many cases it is difficult 
to produce vomiting, but by giving the antimony, we ensure its 
contra-stimulant effects, whether vomiting be produced or not. [One 
of the best emetics and expectorants is the compound syrup of squills, 
(Coxe's hive syrup;) but Dr. Dewees was partial to a combination of 
calomel and tartarized antimony, which has been found of great 
service. His formula directs two grains of the antimony and twelve 
of calomel, to be divided into eight powders, one of which is to be 
administered at intervals of twenty minutes or half an hour. If the 
emetic effect should be severe, give the medicine at longer intervals, 
remembering that the preceding prescription is adapted to a child 
two years of age ; for it is important to observe, that while emesis 
continues, or even extreme nausea, we are not warranted in con- 
tinuing the emetic medicines. This combination of cathartic and 
emetic substances is particularly adapted to these cases of croup, in 
which blood-letting is hazardous or inadmissible.] Brisk purgatives 
are also necessary, until the bowels are freely opened. During 
the whole course of the disease, the warm bath used occasionally 
will be found serviceable. The effect of blisters is often very decisive 
in the first stage, after bleeding and leeching have diminished the 
violence of the disease ; but it is needless to torture children after the 
false membrane is formed. Children can rarely be made to inhale 
hot vapour; if they can, it will be found very serviceable. 

We are informed by Dr. Mason Good, that two physicians of St. 
Petersburg!!, Drs. Harden and Miller, had ventured upon cold affu- 
sion after every other remedy had failed, and the practice was at- 
tended with success ; but no one who understands the pathology of 
this disease, and has seen the appearances on dissection, will believe 
that the false membrane could be removed by such means. 



CROUP. S73 

I have a very high opinion of the action of calomel in this disease, 
if employed early, and not trusted to entirely, to the neglect of gene- 
ral and local bleeding. The more rapidly the system is affected the 
better; and it should be given in doses of two, three, and four grains, 
so that from two to three scruples are taken during the first twenty- 
four hours. If the calomel produce hypercatharsis, it is to be discon- 
tinued, and mercurial ointment rubbed in on various parts of the body. 
The mercurial treatment should not, however, be too long persisted 
in ; if it have any effect, it should be seen within the first thirty or 
thirty-six hours. It is impossible to say in what manner the calomel 
acts.* Dr. Mason Good says, " it not only acts by exciting a salutary 
revulsion or conira-actiou, but breaks down the thicker parts of the 
blood from which the membranous secretion is principally furnish- 
ed !" — Page 427. Dr. James Hamilton, jun., was once a mercurial 
champion of the highest order; he used calomel in very large quanti- 
ties ; but he has now changed his opinion, and considers it in the light 
of a poison, in almost every other disease hut syphilis. Is there an 
individual in the British' empire, with an ordinary share of common 
sense, who, having cured forty-six out of fifty cases of such a dread- 
ful disease as croup, by means of the action of calomel, which Dr. 
Hamilton alleges he has done,t would not feel justified in recom- 
mending others to follow the same treatment ? But this useful 
remedy has since been cast in the back-ground, and he has had the 
extreme folly to state, " that the action of the mercury tends, by ex- 
citing inflammation and effusion, to produce thickening of various 
membranes, particularly of the pleura."J 

Bronchotomy has been frequently recommended in croup, and 
occasionally successfully practised. There are cases in which it ought 
to In' performed, because there is a possible chance of success; and 
there are others in which such a step will only tend to bring surgery 
into disgrace. If the disease be confined to the larynx and upper 
part <>i the trachea, we ought not to hesitate when suffocation is 
threatened; but if the membrane extend into the bronchial tubes, or 
I •• complicated with extensive bronchitic inflammation and effusion 

into both lung's, i! will In- improper. It appears to me that broncho- 
tomy should be had recourse lo m the three following circumstances 
only: — In inflammation of the larynx, threatening suffocation; — 

when foreign bodies have accidentally found ihcir way into the 
larynx; and in the peculiar affection of the epiglottis, larynx, and 

lima glottidis, winch was first minutely described by Bayie. 

When performing this operation in a case of croup, it should be 
always kepi in view, thai, if the disease be far advanced, the false 

membrane has a tubular form; in fact, it has taken the shape of the 

Canal, from the surface of winch n is very easily separated j so that 

when the incision is made through the cartilages, the membrane may 

collapse from the pressure of the atmosphere, and produce instant 

load by exciiing copioni secretion In tbe mucoos glands ancTcrypiBs, 
which ire mi Bbondanily distributed (bronghooi the lining membrane of the rcs|ura- 

lurv 10 

t ■■ i lo the Due and Abnae of Mi > ;rv," <fcc. p. 20G. 
x Idem, p. 919. 
32 



374 CROUP. 

death. Before quitting this subject, I may mention that Bretonneau, 
in the epidemic which he described, trusted at last entirely to the ac- 
tion of mercury, and the local application to the inflamed tonsils, of 
pure muriatic acid; and he assures us that the practice was attended 
with great success. With regard to calomel, he says, at page 94, that 
its good effects were perceived in a few hours after the administration 
of the first doses. But after a careful perusal of the work, and the 
result of the practice, I see no reason to alter the opinions already 
expressed. 

Chronic inflammation of the trachea requires the frequent applica- 
tion of leeches and blisters; inhaling the vapour of warm water or 
tar, together with an occasional emetic; the steady use of laxatives; 
warm clothing, and farinaceous diet. 

The disease described by Bayle, and to which several allusions 
have been made, is an oedematous affection of the larynx, glottis, and 
epiglottis. I conceive, however, that it is often owing to the swell- 
ing'produced in the first stage of acute inflammation of the mucous 
membrane also, when it is swollen and dry; and also to chronic in- 
flammation, which is not attended by oedema. It is sometimes 
produced by sudden congestion of the vessels of the mucous mem- 
brane, which had previously been in a state of irritation, as I shall 
attempt to show, when treating of the pathology of hooping-cough. 

It appears to me, that this is the disease which sometimes goes by 
the name of spasmodic croup. And the same pathology likewise 
serves to account for the phenomena of the affection which is com- 
monly known by the appellation of crowing disease. 

It is probable, that this is the true pathology of the disease de- 
scribed long ago by Miller, and afterwards noticed by Parr and others, 
under the denomination of spasmodic asthma of children. 

It is supposed that croup is a disease consisting of a combination 
of inflammation and spasm; but that spasmodic croup consists en- 
tirely of spasm. Occasionally, children die after giving a single crow, 
and I had once an opportunity of seeing a man 40 years of age die 
in a few hours from the first attack. Upon minute inquiry, it will be 
found, however, that individuals, cut off in this sudden manner, 
have for some days or weeks laboured under what is called a com- 
mon cold. 

I am inclined to believe that this disease may be produced by 
cerebral irritation, causing a morbid action in the nerves that supply 
the muscles of the throat, and wljjch, by producing a convulsive 
spasm, occasions the contraction of the larynx, so as to produce the 
following phenomena. 

Symptoms of spas?nodic croup. — Children are generally seized 
in the evening, or during night, with a sense of coldness over the 
whole surface, and laborious breathing. During inspiration, a long 
shrill sound is produced, alternately with coughing, and occasionally 
weeping, when the voice is observed to be hoarse and croaking. 
There is a sense of constriction in the throat, an expresson of great 
anxiety in the countenance, with lividity of the cheeks and lips. 

These phenomena are produced by the application of cold, and 
even by cold feet ; they frequently occur during dentition. The bowels 



CROUP. 575 

are almost always found to be in a neglected state. The disease is 
rarely fatal. 

On dissection, the lungs will be found in general loaded with dark- 
coloured blood, so much so, as to have lost a great deal of their 
natural colour and buoyancy. At one time, I was disposed to regard 
this condition of the lungs as the disease, till a fatal case occurred, at 
the dissection of which I had the able assistance of Mr. Syme, who 
displayed the state of the mucous membrane of the larynx in the 
most satisfactory manner, and drew my attention to the memoir 
written by Bayle. The following is a history of the case. 

Edward Currie, aetat. 40, a labourer. — Up to the period of the great 
fires in Edinburgh, which took place in November, 1824, he had 
always been a healthy, stout man. During his attendance in work- 
ing the engines, and carrying water, he was exposed to cold and 
wet, and was subsequently affected with what he called a severe cold 
and sore throat, attended by occasional headaches; but having a 
large family, and being of industrious habits, he continued to work 
at his daily labour. On the 2d of January following, he became 
worse, and was unable to go out, but sat at the fireside almost the 
whole of t lie day, complaining of chilliness, sore throat, and tightness 
about his chest. After passing a restless night, he sent to my dis- 
pensary for assistance on Monday. At 5 o'clock in the evening, he 
had severe rigors with difficulty of breathing, and at half past six, 
was visited by one of my pupils, Mr. Marshall, (now of the S7th 
regiment,) whose name is associated with many other interesting 
cases, and from whom I received the following report : — " On seeing 
him, I believed he had caught a cold : he complained of sore throat, 
and evinced some uneasiness in swallowing, but there was no ap- 
pearance of inflammation of the fauces, nor pain on pressing the 
wind-pipe. The rigors were still severe, the pulse strong, beating 
about 70 in the minute, and there was a sense of constriction in the 
1 bled to the amount of IS oz., during which the rigors 

. '.in afterwards returned." 

Mr. Marshall thought his patient in no danger, and that the symp- 
toms would soon give way to the remedies prescribed ; but in about 
an hour after he toolc bis leBTe, the dyspnoea became much worse, at- 
tended With Bevere rigors. Mr. Davidson, a respectable surgeon in 
the' neighbourhood, Was immediately seril lor. who found the man in 
Stoch a dangerous Btate, that he wished me to be present before any 
further step was taken; but soon the symptoms became so much 
more Urgent that be could wait no longer, and be opened a vein in 
tip; arm ; the blood was flowing on my arrival. About IS oz. were 
■Detracted with very little or no relief: although a large orifice was 
made, tin: blood did not flow in a stream, and it was very dark- 
coloured and thick. It coagulated very imperfectly^ yielded no 
lernm, and bad every appearance of what is commonly called " dis- 
solved putrid blood." The Btate of the respiration sometimes 
mbled that which is heard in croup, after the formation of the 

im mbrane ; a' others, that of hooping-COUgh, during the parox- 
ysm j indeed; the similarity was so L'reat, that I heard a number of 
won, ing the point. It was ascertained that he experienced 



376 CROUP. 

the greatest difficulty in breathing during the act of inspiration, 
when he made the shrill crowing noise. There was cough. He 
spoke distinctly after the bleeding, which he could not do before, 
but it was in a low voice, and the exercise seemed to cost him a 
considerable effort; he said <■• I feel rather better." His face was 
pale and anxious, and I was told that it had been so for several 
hours; pulse rapid and feeble. Upon being subsequently asked if 
he had any pain, and where it was situated, he replied by placing 
his hand upon the thorax, and nodding. During the momentary 
absence of Mr. Davidson and myself, in an adjoining department, the 
patient felt a desire to make water, and actually got out of bed un- 
assisted, and lifted the chamber-pot. Upon our return, he was 
cautioned to lie down, and on no account to make such an exertion 
again; but he persisted, declaring he felt somewhat better, and in a 
moment afterwards he was dead. 

The body was opened thirty-six hours after death. The follow- 
ing were the appearances observed. Right lung attached throughout 
its whole extent, by old adhesions to the pleura costalis; left lung 
free. The lungs and trachea were then carefully dissected out, in- 
cluding the root of the tongue, and minutely examined. The lungs 
were of a very dark colour, heavy, and gorged everywhere with 
dark-coloured blood ; although there was no hepatization, yet two- 
thirds of these organs, when cut in small pieces, sank in water, a 
little below the surface; this was proved not to depend on alteration 
of structure, for by washing they were restored to their natural colour 
and buoyancy. The mucous membrane everywhere in the larynx, 
trachea, and bronchial tubes, was of a dark red colour, and coated 
with reddish mucus; but the bronchial tubes were not gorged with 
it, as seen in the lungs of those who die of bronchitis; the larynx 
was found so much ossified, that, after being slit open, it could not 
be separated to any extent; the mucous membrane at this part was 
found so much swollen, as to leave the smallest possible passage 
for the transmission of air at the superior, but particularly the in- 
ferior aperture; the epiglottis was much swollen, erect, stiff, and of 
a red colour. 

Treatment of spasmodic croup. — This affection in children fre- 
quently terminates after copious perspiration, so that nurses have 
been led to put them as soon as possible into a hot bath, which is in 
general efficacious, and it is the first thing to be done. An emetic 
ought also to be given, and if these means fail, a vein should be 
opened, and a moderate quantity of blood abstracted, or leeches 
applied about the larynx. This is the case of all others for broncho- 
tomy, and I confess, that it is probable the life of Currie might have 
been saved, if the operation had been had recourse to. M. Thuilier 
has recommended compression, from time to time, of the oedematous 
epiglottis, which cannot be easily effected ; and if it could, little ser- 
vice would follow, as it is the condition of the membrane at the rima 
of the glottis, which occasions the danger. Bayle proposed the intro- 
duction of a sound into the trachea, failing which, bronchotomy. 
Lisfranc suggested that incisions should be made into the oedematous 
parts, to facilitate the discharge. 



CROUP. S77 



FALSE CROUP, OR CROWING DISEASE. 

The croicinsr disease usually commences with teething. The 
infant is observed to make a shrill sound during inspiration, when 
there is an unusual paleness of the face, or flushing. It occasion- 
ally appears terrified, clings to the nurse, and the eyes are suffused 
with tears. There may be one such attack during the day, or the 
infant may be constantly affected. After cutting a pair of teeth, 
there may be no appearance of the affection till the next set occa- 
sions irritation of the gums. The crowing disease is sometimes 
connected with inflammation of the mucous membrane of the air- 
passages, with cynanche tonsillaris, and with febrile complaints ; 
these are dangerous complications. At other times, we can distinctly 
trace cerebral disorder. This is likewise a dangerous complication, 
and there is no doubt that it is aggravated by disorder of the sto- 
mach and bowels. Experience has convinced me, that, for the most 
part, the children affected in this manner have large heads, and are 
plethoric. 

Treatment. — If there be plethora and febrile action, leeches should 
be applied to the throat, in such numbers, and repeated, as the ur- 
gency of the case may require. The bowels should be freely acted 
upon by any laxative, but it is sometimes necessary, from the mor- 
bid appearance and odour of the evacuations, to have recourse to a 
mercurial preparation. The gums should, if necessary, be freely di- 
vided, and the warm bath used morning and evening. [As the sud- 
den access of the paroxysm calls for immediate relief, a hot, saline 
pediluvium and a simple emetic of ipecacuanha should be at once 
resorted to. If the child's bowels are confined, these measures may 
be preceded by an injection of assafoetida. When a general bath can 
be obtained in time, it is to be preferred to the pediluvium; and either 
should be followed by a dose of calomel and opium.] 

It is of importance to attend to the diet, to reduce plethora, and 
r to load the Stomach. A solution of antimony should be used 
rionally, either as a contra-stimulant, an emetic, or diaphoretic, 
in doses corresponding to tin: object we may have in view. The in- 
tuit should be well clothed, and never taken out of doors, in a cold 
or damp day. When the head feels hot, or when there are marks 
of cerebral disorder, the head may he shaved and kept cool; the 
bowels are in be 1 1 1 < > r* r freely acted upon ; frequent doses of calomel 
may be- prescribed for a lew days, and croton oil or antknonial oint- 
ment, applied to the head, to produce irritation and pimples on the 
surface of the scalp. This last-mentioned part of the treatment is 
very important, and mast be persevered in, producing crops of pus- 
tules occasionally, lor a considerable period of time. Change of air 
is sud to have worked wonders in ibis complaint I have seen it 
beneficial when the child was removed from a cold bieak situation 

to a milder and more sheltered spot; but I have more frequently ob- 
of air hurtful. 

[• Svn. — Larynglsmm -triiiuius.— Asthma infantum.] 

- 



378 HOOPING-COUGH. 



PERTUSSIS. HOOPING-COUGH. CHIN-COUGH. 

This disease is also known by the appellations chin-cough, kink- 
cough, &c , and it is probable that it is not a disease of such recent 
origin as has hitherto been imagined. Gardien very sensibly states, 
that if it has not been described in France until the year 1814, it is 
because it has always been confounded with other species of cough. 
Indeed, some pretend that it was known to Hippocrates, while 
others assert that it was imported in more recent times from the east. 
It is not of much consequence how this matter really stands, because 
the most perfect knowledge as to its true origin would not enable us 
to treat the disease more successfully. Hooping-cough is a disease 
of childhood, although I have seen many instances in adult age. 
Heberden says that he has seen it in a woman of threescore and ten, 
and in a man eighty years of age. It may be said to occur once 
on'y in a lifetime, but several cases have fallen under my notice of 
secondary attacks. Dr. Rosenstein states, in his work on the diseases 
of children, &c, that in Sweden, in the course of sixteen years, from 
1749, forty-three thousand three hundred and ninety-three children 
died of the hooping-cough, which gives an average of 2712 per an- 
num; but in the year 1755, five thousand eight hundred and thirty- 
two children died of this distemper. In general the annual mor- 
tality amounted to from seventeen hundred to two thousand in that 
kingdom. According to Dr. Watt, the deaths from hooping-cough 
in Glasgow, have been pretty nearly 5§ per cent, of the whole 
deaths in that city: the greatest number in any one year took place 
in 1809, when they amounted to Hi per cent.; and he concludes 
that next to the small-pox formerly, and measles now, chin-cough is 
the most fatal disease to which children are liable. He gives a table, 
which appears to prove that in young children there is more danger 
than in those further advanced in life ; which does not altogether 
accord with my experience.* 

Phenomena. — In the first stage of hooping-cough, the disease is 
almost always confounded with a common slight catarrh : the dura- 
tion of this stage varies very much ; in general, however, it extends 
from ten to twenty days. There is a dry cough, occasional sense of 
constriction in the chest, and a feeling of weight in the head. The 
eyes are sometimes a little swollen and red, with frequent sneezing, 
and involuntary tears ; in many cases, there is little or no fever ex- 
cept during the night; the bowels are generally out of order. We 
sometimes suspect the disease to be hooping-cough, because it is 
epidemic at the time, or in consequence of the convulsive appearance 
of the paroxysm of coughing. At last, however, the cough assumes 
a peculiar character; when this takes place, the disease is said to be 
in the second stage. It is characterized by an inspiration which is 
long and sonorous, producing a peculiar shrill noise, which is termed, 
in common language, the hoop or kink, to which succeeds an expira- 

* It affords me great pleasure to refer the reader to Dr. Watt's work on Hooping- 
cough, as the best which has ever been published ; and to that of the late Dr. Marcus, 
of Bamberg, who died the day after he sent his preface to the press. 



HOOPING-COUGH. 379 

tion, which is broken by frequent fits of coughing. No one who has 
seen the disease when fully formed, can mistake it. When the cough 
commences, in slight cases, the features become a little swollen, the 
face red, the eyes suffused with tears ; the cough, which is frequently 
interrupted by a long inspiration, is hoarse ; the paroxysm ceasing 
with an expectoration more or less copious, frequently assisted by the 
act of vomiting, which discharges the contents of the stomach. As 
soon as this is accomplished, children are commonly able to return 
to their usual amusements, and appear to suffer little or nothing, 
until towards the period of the next paroxysm. The appetite is in 
general good. The expectoration is at first slight, scanty, and viscid; 
but if the disease goes on in a favourable manner, the discharge 
becomes more copious, and less tenacious. Young children scarcely 
ever spit out the expectoration, unless during the act of vomiting : 
it is generally swallowed as soon as discharged from the air-pass- 
ages. 

The patient is in general warned of the approach of the paroxysm, 
by a greater or less degree of chilliness on the surface, and a tickling 
in the throat, immediately succeeded by a sense of tightness both in 
the larynx and chest, and a dread of suffocation, which induces him 
to fly to his nurse, or to lay hold of any thing within reach, for sup- 
port during the fit. Others seem to derive relief from laying all-fours 
on the ground, and when the discharge has taken place, they jump 
Dp and run about. 

In more severe cases, the sense of suffocation is dreadful; the re- 
spiration is much more impeded ; the cough more intense and pro- 
tracted ; the features more swollen, and of a livid colour; the eyes 
seem ready to start out of their sockets; the eyelids are much swollen, 
and the cheeks, perhaps, bathed in tears; till at last expectoration 
place, when the children pant for breath, and are unable to 
return to their play for a considerable time. The skin is above the 
natural temperature, particularly at night.; complaint is made of 
head tche ; tie- appetite i> bad, the bowels are much disordered, the 
tongue loaded, and flatulent distension aggravates the patient's suf- 
■ 

Th" straining which talcs place during the paroxysm is sometimes 
pro In.--: tin- involuntary discharge >>f faeces an. I urine. 
It 1- no uncommon thing for a small blood-vessel to give way in the 
conjunctiva, producing ecchymosis; haemoptysis occasionally occurs, 
hut this is rare in comparison t<> epistaxis, which is very frequent, 
and, when it takes plaee in plethoric children, is considered a very 
fortunate occurrence. 

In the worst forms of the disease, fever is constantly present, and the. 
breathing isalwaysmore or less impeded, which shows that some mis- 
chief is going on internally. Fits of temporary asphyxia are frequent; 
they air very often mistaken lor convulsions, and by them children 
imetimes instantly cut oil'. Indeed, children have been Known 
to die suddenly during a p iroxysm, asphyxiated, whose cases were 
previously slight, and not attended with (ever. In some instances, 
convulsions occur and c my oil" the patient. 

Many oil! met with in practice, are those in which 



380 HOOPING-COUGH. 

this disease is engrafted, as it were, on bronchitis ; or succeeds to 
small-pox or measles. 

Causes. — Hooping-cough is rarely sporadic; it generally prevails 
as an epidemic. Some assert that it is unquestionably contagious, 
while others allege that it is not so. Some suppose that it is a dis- 
ease produced by a miasm of a specific nature. Any discussion on 
these points is quite unnecessary. 

Appearances on dissection. — I have had fifty opportunities of ex- 
amining the bodies of those who died of this disease.* In one severe 
epidemic, we had upwards of two hundred cases at the dispensary, out 
of which there were thirty-two deaths. The appearances found on 
dissection were very uniform, according to the period of the disease 
at which death took place. I have seen two dissections of children 
who died asphyxiated, during the paroxysm, and in these the lungs 
were found to be gorged with blood; the whole lung, when put into 
water, showing far less buoyancy than natural, and large portions, 
when separated, were found to sink to the bottom of the vessel. But 
it was proved that this increase of gravity was not owing to altera- 
tion in the texture of the organ, which resumed the natural colour, 
appearance and buoyancy, when deprived of the blood by washing. 
The right side of the heart and the large vessels near it were dis- 
tended with dark blood. The mucous membrane of the air-passages 
everywhere presented a dark red appearance, seemingly thickened, 
the tubes containing more or less mucus tinged with blood. The 
brain was not examined. 

In ordinary cases, when death takes place during the second, third, 
or fourth week, the following is a sketch of the appearances. In the 
head, marks of vascularity and of venous turgescence,and sometimes 
also effusion of serum between the membranes, and in the ventricles; 
but these were far from being invariable appearances. In some few 
cases, there was great vascularity, and some effusion at the base of 
the brain, more particularly at the origin of the nerves, but not to a 
greater extent than has been frequently remarked in bronchitis, and 
other diseases in which there was no tendency to spasmodic cough, 
or to spasm of any kind. In one case, which was accompanied by 
violent and intractable convulsions, with considerable rigidity of the 
superior extremities, the substance of the brain had a rosy tint; on 
making sections, large drops of blood quickly exuded from nume- 
rous points on the cut surfaces. On exposing the lateral ventricles, 
the left coiyus striatum and thalamus were observed to be enlarged, 
particularly the former ; in so much, that on measuring the depth of 
the brain on each side, it was discovered to be nearly half an inch 
deeper on the diseased side than the other; when cut, it was found 
to be rather harder than the corresponding parts on the opposite side. 
The child had previously enjoyed a good state of health, and even 
after death did not appear much emaciated. 

* It maybe mentioned as a remarkable fact, evincing the improved state of society, 
and the advantages of education, in removing prejudices and destroying superstition, 
that, in Edinburgh, we are rarely prevented from examining a body after death, if 
sufficient attention has been paid by a medical man during the course of the illness — 
except by the poor Irish population, who seem to have a more superstitious regard 
for their dead on this side of the channel than in their own country. 



HOOPING-COUGH. 381 

Traces of disease were invariably found in the thorax. On some 
rare occasions, the lungs were somewhat collapsed; but in general 
they completely filled their respective cavities. In a few instances 
the pleura cos-talis was covered with lymph like an unctuous secre- 
tion. Once or twice the lungs adhered to the walls of the chest, by 
an intermediate deposition of soft coagulating lymph. The anterior 
surface of the lungs, in almost all cases, presented spots of a whitish 
appearance, as if coated over with lymph; but this was found, upon, 
closer examination, to depend on emphysema, air being effused be- 
neath the pleura, from the rupture or enlargement of the air cells ; 
considerable portions were observed gorged with blood. Sometimes 
the substance of the lungs was in a state of oedema; and occasionally 
portions were observed inflamed. 

In persons who were not cut otf till the eighth or tenth week, 
tubercles in various states were frequently observed ; sometimes 
vesicular or crude, large and solitary, sometimes softened, and 
partly discharged by expectoration. On one or two occasions, I 
h ive seen one lung infiltrated with a soft caseous matter. The 
bronchial glands arc found enlarged, if the patient do not die before 
the third or fourth week. 

The mucous membrane, throughout the air-passages, has always 
displayed more or less vascularity, winch increased towards the 
ramifications, and the tubes were found filled with matter which 
had more or less resemblance to pus. In the trachea and larynx, 
this secretion is observed, but I have never seen them filled with it 
like the bronchial tubes. Sometimes flakes of coagulablc lymph 
arc observed, and ulcerations about the glottis, in the larynx and 
i, but more particularly at the great bifurcation. 

In the abdomen, sometimes every structure appears to be in a 
healthy state; at others, the liver is found gorged with blood, some- 
times whiter, at others redder than natural. The mucous membrane 
Of the Btomach and bowels has Bhown various red patches, and I 
itions in the colon, and enlargement 01 the mesente- 
mds. 

The late Mr. AJcock, a scientific general practitioner in London, in 
of the numbers of the Medical Intelligepcer, states, that he "has 
rtained, by dissections of patients who have died of 
hooping-cough, that the larynx invariably exhibited signs of inflam- 
mation, often to so great an extent, as by its swelling to close me- 
chanically the glottis; often the exudation ofcoagulable lymph near 
the larynx, the mucous membrane of the trachea and bronchia much 
inoreased in vascularity, and the cavities of the latter filled with 
fluid, more or less mixed with air, the appearance of the Quid vary- 
from thin mucus to perfectly formed pus." This extract was 
ented t<» me by a friend one day after my lecture ii| this sub- 
ject, and I have never been able to procure the number ol the peri- 
il which contains the whole of the paper. I have thought it. 
right, however, to give the extract, and to express the high respeel I 
enteri tin for M. \ . from the accounts which have reached me, 
at different hit seal and indefatigable exertions for the im- 



38-2 HOOPING-COUGH. 

These post-mortem appearances correspond with the dissections 
recorded in Dr. Watt's treatise. 

Pathology. — Until lately, the most uncertain opinions prevailed 
respecting the nature and seat of this disease. Some supposed it to 
be a nervous affection, and of a true spasmodic character. Cham- 
bon and others assert that it is a true catarrh of the stomach. Some 
represent it to be a pure inflammation of the mucous membrane 
of the larynx, trachea, and bronchial tubes, to their termination in 
the air-cells. While there are others, like Gardien, who think that 
the disease is partly situated in the lungs, but that the essence of it 
consists of a spasmodic affection of the glottis and diaphragm. In 
consulting the works of Willis, published in the year 1670, it will be 
seen that nothing was then known of the nature and seat of hooping- 
cough, and from the general want of success in treating it, this 
branch of practice fell into the hands of old women and quacks. 
According to the Brunonians, it is a disease of true debility. Some, 
indeed, conjoin it with typhus ; while others allege that it depends 
on inflammatory action in the brain. Rosenstein places the seat of 
hooping-cough in the nerves of the chest, and Hufeland agrees with 
him in that opinion. Autenreith declares he found the pneumo- 
gastric nerves inflamed. Breschet seems to support this opinion, but 
although this state of parts may have occurred on some occasions, it 
is denied as a more common cause by other authorities. Guersent 
has stated, that he opened a number of bodies with a view to deter- 
mine the fact, but he did not find the pneumogastric nerves diseased. 
No pathological information can be derived from Cullen's works, or 
even from Dr. Thomson's recent edition of them, respecting this, or 
any other disease; but according to his nosological arrangement, it 
is evident he thought it to be of a nervous and spasmodic nature. 
Dr. Gregory, it would appear, gave up the investigation of the nature 
and seat of the disease in despair, for he used to make the following 
statement in his lectures: — " 1 do not attempt the proximate cause, 
though I may mention I have no faith in the theory that was ad- 
vanced some years ago, that the disease depended on the stomach ; 
it is more probable that it is seated in the lungs." Yet he considered 
it to be of a spasmodic nature. 

The oldest opinion which can be traced, approaching to the true 
pathology of this interesting disease, is that which was advanced by 
the celebrated French writer Astruc, who states, (at page 142 of his 
Treatise on all the Diseases of Children,) that " this disease prin- 
cipally consists in inflammation of the superior part of the larynx 
and pharynx, and more particularly of the latter, which is sometimes 
ulcerated with the constriction of the glottis, as dissection proves." 

It appears to me, that investigators have been bewildered in en- 
deavouring to discover the first link in the chain of diseased action, 
and by the character of the cough, with regard to which, it should 
be recollected that a very slight degree of irritation in the larynx, 
and even about the glottis, will produce most violent convulsive fits 
of coughing. Dr. Watt says, that the cough is exactly what may 
be produced by any very violent irritation applied to the same parts, 
" of which, (says he,) I had a very striking proof some time ago. 



HOOPING-COUGH. S83 

Two children had differed about their play ; the one, who supposed 
himself ill used, to be revenged on the other, took a handful of saw- 
dust, and endeavoured to thrust it into his mouth. He succeeded in 
his attempt. The other, crying and struggling for relief, allowed a 
quantity of dust to be drawn into the windpipe. This gave great 
uneasiness, and after a short time excited violent convulsive fits of 
coughing, which exactly resembled those of the chin-cough. Even 
the hoop was very distinctly formed. At first he spat up nothing, 
afterwards thick mucus; at last, the irritating cause being removed 
by the expectoration, the other symptoms disappeared. This was a 
very striking example of chin-cough being brought on artificially." 
I have sometimes seen the same effects in both old and young, from 
articles of food, and particularly small portions of sweet-meats, going 
the wrong way, as it is termed, i. e., dropping into the larynx, or 
adhering somewhere about the margins of the glottis or epiglottis. I 
was once present at the dissection of a shoemaker, who died from 
extensive inflammation of the throat and windpipe, and who had, 
during the whole of his illness, of four days' standing, violent con- 
vulsive fits of coughing, with a complete hoop. On examining the 
throat and air-passages, extensive inflammation was discovered, and 
a small piece of a hog's bristle was found sticking in the margin of 
the glottis. 

My opinion of the nature and seat of the hooping-cough is as fol- 
lows : — There is something peculiar in the disease, since almost no in- 
dividual escapes contracting it once in his lifetime. I have no doubt 
that the nervous system is involved in the affection — very seriously 
involved ; but in I he present state of our ignorance of the structure 
and functions of that system, the doctrine of spasm must be very 
oautiously received into the medical evidence of the case, more par- 
ticularly as all the phenomena can l>o satisfactorily explained without 
its aid. The essence of the disease consists in irritation and inflam- 
mation of the mucous membranes of the body, but more particularly 
of tli<: air-passages. This is proved by the pectoral or catarrhal 
symptoms, winch are to be observed from the very first onset of the 
y the increased secretion ; and by the result of dissections. 
Some say the disease cannot be a consequence of inflammation, 
use there ii no febrile excitement in the pulse in slight cases, and 
no increased heal of surface ; but it is a fatal error to suppose that 
inflammatioD cannot exist without fever. In the majority of cases 
of hooping-cough, the inflammation, although extensive, is only 
tlightly tub-acute, and there is consequently no heat of skin — no 
increa ed velocity of the pulse — no thirst; but when the inflam- 
mation runs a little higher, then we generally have these constitu- 
tional symptoms. Ii will be observed, <»n perusing the description of 
tins disease given by every author, thai it begins with the common 
symptoms oi catarrh, from which it cannot, during the first stage* be 
distinguished. 

The disease, when formed, comes on in paroxysms. I shall not 

stop to 1 1 1 • j ii i r< : whether these paroxysms are occasioned by a pecu- 

iflectiofl Of th': nervous system or not. The paroxysm com- 

meoOM with I SOPSa ul coldness on the surface, making an irregular 



384 HOOPING-COUGH. 

determination of blood, that takes place towards the lungs, which, 
perhaps, never will be satisfactorily explained. These organs become 
gorged with blood, and the air is consequently prevented from ob- 
taining a free passage through the ramifications of the bronchi and 
air-cells; some degree of dyspnoea is produced, with tightness in the 
chest, and a sense of suffocation. All the powers of the constitution 
are brought into play to remove this congestion ; violent coughing is 
excited — all the voluntary muscles are called into excessive action, 
and a universal muscular commotion is produced, which tends to 
force the blood on in its circulation— a copious secretion takes place 
from the mucous membrane, probably throughout the whole extent 
of the air-passages; and the fit ceases when the mucus is discharged, 
which is sometimes promoted by the act of vomiting. Towards the 
close of the paroxysm, a determination of blood takes place to the 
skin, frequently producing copious perspiration, which is probably 
assisted, if not entirely produced, by the violent muscular commotion 
into which the body is thrown. This is also, perhaps, another way 
by which the congestion of the lungs is removed. 

It is generally believed that the hoop is produced by spasm. It is 
not my business to attempt to disprove this assertion; but I have 
already shown that the hoop has been produced by extraneous bodies, 
which have found their way into the larynx, or have been lodged 
about the glottis. It has also been shown, that in pure inflammation 
of the mucous membrane of the larynx, before and after the effusion 
of coagulable lymph, the same sound has been heard; and also when 
the cahbre of the larynx at the rima glotlidis has been diminished 
by mere swelling of the mucous membrane, as well as by effusion, 
forming the disease which Bayle has described under the name of 
oedema glottidis. In all these cases, there is the long sonorous or 
shrill inspiration. Cullen says, (in the 1404th paragraph.) that "the 
peculiar sound is produced by air rushing through the glottis with 
increased velocity." It is admitted that this is occasioned by the 
diminution of the canal through which the air has to pass, and the 
only question to decide is the cause of this diminution. Cullen and 
others assert that it is owing to the spasmodic contraction of the 
muscles of the throat, which are connected with the larynx; while I 
presume, that it is generally owing lo the other causes: — the fact is 
capable of explanation in both ways, but the decision will influence 
the treatment. In hooping-cough, we have decided evidence of con- 
gestion and inflammation of the air-passages; the larynx, the parts 
in the neighbourhood, principally suffer, and at the commencement 
of the paroxysm, when blood is accumulated in the lungs, the mu- 
cous membrane, I apprehend, becomes more swollen, and the space 
at the rima of the glottis is diminished, so as to be almost closed. It 
is admitted that the difficulty which the air experiences in traversing 
this part, produces the phenomenon of the hoop, and increases the 
tendency to asphyxia and convulsions. The distension of the vessels 
is probably relieved by increased secretion and determination of 
blood to the surface. 

Sometimes the lungs are not properly relieved from a state of 
engorgement, which, if life be not immediately destroyed, terminates 



HOOPING-COUGH. 385 

in inflammation of the substance of the lungs, or the formation of 
tubercles. 

The brain is frequently affected, not, in all probability, from any 
primary diseased action in that organ, as some have supposed, but 
from the obstructed circulation in the lungs, and the overloaded state 
of the right side of the heart, preventing the free return of blood from 
the head. The brain, as well as every other part of the body, must 
likewise suffer from what may be termed the chemical condition of 
the blood itself, owing to the want of those natural changes which 
take place in the lungs, which are prevented partly by the congested 
state of these organs — partly by the want of a sufficient supply of air 
during each paroxysm — and partly by the diseased condition of the 
mucous membrane. 

Treatment. — Dr. Ferriar, in his Medical Histories and Reflections, 
(vol. iii. p. 215,) says, that " hooping-cough has been too much trusted 
to the management of nurses, and has been empirically treated, even 
by those physicians who have applied themselves to the particular 
consideration of the complaint." Dr. Gregory, in his lectures upon 
this subject, with that frankness and candour which marked his 
career, used to make the following statement : — "I think it proper for 
me to warn you, in the first place, that we have no cure for it." 
Cnllen divided this disease into two stages; the first continues, per- 
haps, for three weeks; during this period, he imagines the contagion 
to be present, and operating on the animal frame. The second stage 
embraces the whole remainder of the disease, should it last for twelve 
months. Dr. Mason Good says, that he believes the hypothesis to 
be correct : " throughout the first stage, (says he,) our attention should 
be directed to whatever will moderate the influence of the contagious 
stimulus, retard the return of convulsive paroxysms, and mitigate 
their violence." 

" Bleeding, (says Mason Good,) in severe cases, will be found ne- 
cessary for this purpose; but it should be avoided, except in severe 
paemodic affections are often rather increased than dimi- 
nished by the use of the lancet ; and it will, in general, be found better 
to employ blisters as a substitute." This paragraph contains almost 
proof I could bring forward, that bleeding, even in the 
pi'- nt a'_'<\is frequently recommended and practised upon unsound 
principles. If bleeding be employed, it is lor the prevention or cure 
for inflammatory, and not spasmodic action •. but it is only in severe 
case*, according to .Mason Good, that bleeding is to be used, "as 
nodic affections are often rather increased than diminished by 
the us,. () | tip: lancet." Now, it appears to me, that if tbe lancet 
tends t" increase a slight spaamodic complaint, it will surely aizirravate 
a .severe <me in a still greater degree. 

ling is not necessary, ma great majority of cases, nay, it might 
prove injurious in some, by interfering with tbe efforts of ihe con- 
stitution; but when the patient has fever, diiiiculty of breathing 
between the paroxysms, a near approach to asphyxia, or convulsions 
during the paroxysm, 01 if be complain of a constant sense of stric- 
ture in h^ chest, ,, r seven headache, I would recommend blood- 
letting, by opening a vein, if the patient be robust, and about two 



386 HOOPING-UOUGH. 

years of age ; and if the air-tubes are not filled with mucus, I have 
frequently seen the best effects from opening the jugular on such 
occasions. It is impossible to say what quantity should be taken; 
it ought to be sufficient to make an impression upon the disease, or 
upon the system. I once saw a boy six years old, labouring under 
hooping-cough, who was in great danger, from the congested state of 
his lungs and brain. I requested the gentleman who was in imme- 
diate attendance, to open a vein, and to allow the blood to flow till 
relief was obtained. At my next visit, I found that 15 ounces had 
been abstracted. He bore the bleeding well, and his condition was 
very much improved. Next day, however, violent enteritic symp- 
toms took place, which were not subdued till after the application, 
in all. of twenty leeches. This boy made a remarkably rapid 
recovery. — It must not be understood that I would recommend the 
same quantity of blood to be taken from every child of that age : the 
case is mentioned to show that a considerable quantity may be ab- 
stracted without necessarily producing any bad consequences, and 
its power in controlling the disease. 

A similar practice must be pursued if the patient be lethargic, 
which, in such cases, marks oppression of the brain, and frequently 
precedes convulsions. Sydenham speaks strongly in favour of 
venesection in hooping-cough.* The following statement will be 
found: "By this practice of venesection and repeated purges, and by 
this only, is conquered the convulsive or hooping-cough ; an obsti- 
nate disorder which scarcely any other method will subdue." 

We must depend upon leeches in young children, as well as in 
older patients, in advanced stages of the disease. The number of 
leeches to be regulated according to the circumstances noticed when 
treating of bronchitis. 

To show the advantage of leeching, even at the eleventh hour, I 
beg to refer the reader to the three cases mentioned at p. 3, Willan's 
Diseases of London. 

It should be mentioned, that hooping-cough is a disease in which 
auscultation should be employed; by this means, we may deter- 
mine whether inflammatory action be going on in the lungs — whe- 
ther it be general or partial — and whether the bronchial tubes be 
loaded with matter: if they are loaded, we should be deterred from 
bleeding, for reasons so much insisted on when treating of bronchitis. 

After I was convinced of the morbid state of the larynx and rimu 
glottidis producing the hoop, or kink, as it is sometimes termed, it 
naturally occurred to me that leeches, applied over the part affected, 
would be attended with the best effects, in cases where the paroxysms 
were severe, and threatening asphyxia. The theory may be wrong, 
but I can speak confidently of the success of the practice. I had an 
opportunity of trying it in twelve cases, in three of which the hoop 
never returned, although the children were previously threatened 
with asphyxia; all the others were relieved in the most striking 
manner ; and had it been necessary, from the re-occurrence of urgent 
symptoms, to apply them again, or had a great number been put on 

* Swan's edit, p., 321. 



HOOPING-COUGH. S87 

at first, I feel persuaded the hoop would have been destroyed in the 
whole. The immediate relief of this symptom, which occurred in the 
case of a lady, when threatened with suffocation, I shall never for- 
get. Five children in one family were under my care, with hooping- 
cough : two of them had considerable dyspnoea between the pa- 
roxysms, with a tendency to asyphxia during each attack, and were 
exceedingly ill ; blood was taken from the jugulars with extraordi- 
nary relief; a third had leeches frequently applied. These three 
recovered speedily. The other two had the disease so favourably 
at first, as not to require any treatment, except keeping the bowels 
open, and an occasional emetic, yet they were the most trouble- 
some cases out of the five, and were double the length of time in- 
disposed. 

A solution of the tartrate of antimony will be found useful, if the 
diseased action in the lungs shows any tendency to increase. In such 
circumstances, tincture of digitalis is often of great service, in con- 
siderable doses. It is often beneficial to employ antimony and digi- 
talis alternately. Emetics have been much overrated in hooping- 
cough. One or two may be of use when the disease is forming ; and 
they may be exhibited now and then, in the latter stages, when the ex- 
pectoration is not easy, and when we know, by auscultation, that the 
bronchial tubes are overloaded with mucus. I have found an anti- 
monial emetic the best, when there is any febrile disturbance; but 
should the emetic be wanted merely to unload the tubes, and par- 
ticularly if the patient be weak, perhaps the sulphate of zinc will be 
found preferable, as it commonly leaves no sickness or depression. 

Gentle purgatives are to be used for the purpose of keeping the 
bowels easy; great mischief is often done by the constant exhibition 
of drastic medicines for weeks together. Many practitioners seem 
to forget that the long continuance of powerful medicines will cer- 
tainly produce great disorder of the bowels, and consequently, foul 
evacuations. 

The antiphlogistic regimen and confinement to one apartment, 
daring the first part of the disease al least, are essential circumstances 
in tin: treatment An occasional opiate, and a warm bath, will be 
found of service as auxiliary remedies 

B lers are necessary in very acute cases; but except in Buch in- 
stances, 'In; contra-irritation produced by the tartar emetic ointment 
will be found m^si efficacious. Tins plan was first recommended by 
Autenreith. 

It has frequently occurred to me to observe, during epidemics of 
ho >ping-cough, thai those affected were sometimes attacked with 
measles, scarlatina, and even small-pox, the cases being much aggra- 
vated during the eruptive fever; but subsequently, upon the appear- 
ance "i ill'' eruption, the phenomenon of the hoop, which gives the 
character t<> hooping-cough, became very much moderated -m two 
or three cases it entirely ceased, tan n generally returned when the 
tion declined; an instance of which is related in Dr. Ferriar's 

ient work :ilre;idv quoted : " MlSfl , ;iL, r ed one year and a 

half, had the hooping-cough in a Bligbl degree lor some weeks. When 
it seemed to be leaving her, she was seized with the measles, and 



388 HOOPING-COUGH. 

there was an appearance of a very large crop of the eruption. Her 
cough was not very troublesome, and no longer resembled the hoop- 
ing-cough. On the third day she was seized with an extreme degree 
of dyspnoea, and a short harassing cough, and the eruption almost 
entirely disappeared. The pulse became innumerable. Leeches 
were applied to the extremities, blisters were applied to different parts 
of the body, and every method was used to renew the eruption, but 
without success. The cough increased, but the dyspnoea began to 
relax, and at length, to my great satisfaction, the type of the hooping- 
cough was renewed, and my patient recovered, by time, and change 
of air. Not one spot of the eruption of measles ran its usual course." 
Dr. Watt notices the same fact, and it now appears strange that so 
obvious a circumstance had been overlooked, as it is evident that the 
irritation was removed from the windpipe by the cutaneous eruption. 

The application of the ointment occasions an artificial eruption 
exceedingly like small-pox. Autenreith considered it a certain spe- 
cific, when a copious crop was produced on the epigastric region; 
and he distinctly assures us, that the use of the ointment for twelve 
days produces a cure ;* but the result of my practice does not author- 
ize me to make the same statement; therefore I am persuaded Au- 
tenreith could not have met with such severe cases as I have occa- 
sionally happened to treat, particularly in the epidemic which existed 
in Edinburgh about four years ago. His theory of its action, how- 
ever, perfectly coincides with mine, that " when the irritation is well 
established, it acted by directing the blood to the surface from the 
air-passages." It may be shortly stated, that I have seen it very ser- 
viceable in this disease, so much so, that I always have recourse to 
it; and it is afar more beneficial method of producing irritation in sub- 
acute and chronic inflammations, than that by blisters, because it is 
more permanent. The proportion of tartar-emetic in the ointment, 
is a drachm to the ounce. The antimony may also be applied, by 
sprinkling it on the surface of a pitch or warm plaster. 

Several curious circumstances have attracted my notice, with 
reference to the external application of this remedy. In five or six 
cases, when it has been rubbed over the epigastric region, violent 
vomiting has been produced, which was proved to be owing to the 
antimony, by leaving off the ointment, and returning to it several 
times. When applied to the chest, the eruption sometimes appears 
on the genitals and groins; when this was first observed, I thought 
it had been produced by negligence, but I have since seen the same 
circumstance, in cases where every care was taken to prevent any 
accidental application to these parts. 

When the internal disease is severe, it is in general difficult to 
establish the cutaneous irritation by the application of the ointment. 
I have remarked, in three cases, when indiscriminately applied over 
both sides of the thorax, that the eruption did not appear on that side 
in which the diseased action was most violent, while there was a 
copious crop on the other; and in one of the cases, the line of demar- 
cation was exactly in the mesial plane. 

* I have reason to believe that Autenreith has changed his opinion, upon more 
enlarged experience of the remedy. 



HOOPING-COUGH. 389 

Dr. Cullen, from the hypothetical notion that the disease continued 
during the second stage, merely by the power of habit, recommended 
antispasmodics or tonics ; he therefore advised opiates and Peruvian 
bark. Dr. Hufeland likewise recommended belladonna, considering 
the disease to be of a true spasmodic nature ; he gave it in doses of 
a quarter of a grain morning and evening, to children between three 
and six years of age. Ext. conii was formerly in great repute. As 
tonics, small doses of zinc, arsenic, and nitrate of silver have been 
employed. In Russia, the berries of the spurge laurel are said to be 
specific; they are employed, it would appear, as stimulants and 
antispasmodics. The sulphate of alumen has been highly extolled. 
But it would be no slight task to give a list of the remedies which 
have been strongly recommended. There is a popular feeling in 
favour of garlic, applied externally in the form of ointment or tinc- 
ture, and the internal use of a solution of cochineal. Camphor is 
supposed by the vulgar to be an antidote. 

During recovery, it is of the greatest consequence to attend to the 
clothing, diet, and exercise of the patient; I have frequently traced 
relapses to cold feet, and to indigestible food. Laxatives are neces- 
sary, and the cold bath is in great estimation with some practitioners; 
of Which last, I cannot give an opinion: but I have seen the greatest 
advantages in this disease, and many other cases of chronic bronchial 
affections, from sponging the body with water, or vinegar and water, 
two or three times a day. Change of air is extolled by some indi- 
viduals, but is often productive of great mischief, by occasioning a 
return of the disease. It is an important fact, that during the late 
epidemic, which was the most severe I have ever witnessed, all the 
children that were moved for change of air had the disease the 
longest. The children of two families, who had it in the very 
slightest form, were taken to the country when nearly cured; most 
of them had relapses, not only upon going away, but also on return- 
ing. The cause of relapse, in such cases, is easily explained; the 
patient may be moved from a warm situation to a damp, cold one; 
<>r he nay be pal into b damp bed; or a change of weather may 
place when on bis journey. It is a common practice to send 
hooping-cough children to tan-yards for a considerable part of the 
day ; but really, the pathological notions upon which this practice is 
founded, need no refutation. 



33* 



CHAPTER III. 
PNEUMONIA. 



This disease has received various denominations, as peripneumo- 
nia and pneumonitis; and consists of an inflammation of the paren- 
chyma of the lungs. The term pleuro-pneumonia, is employed to 
express the coexistence of inflammation of the pleura and lungs. 

[Pneumonia is most frequent in cold and changeable weather, 
especially at the breaking up of winter. It has been ascertained by 
the observations of Dr. Clermont Lerubard, that this disease has a 
preference, in the proportion of three to one, for the right lung, which 
he endeavours to explain by the greater size and transverse direction 
of the corresponding branch of the pulmonary artery. With respect 
to the ages most liable to pneumonia, the same author draws the 
following interesting conclusions, viz. Adults are less subject to it 
than infants : in the former it is most common between the fifty-fifth 
and eighty-fifth years, and between the twenty-third and twenty- 
seventh years. The juvenile periods in which it most prevails, are: 
1. The first or second year. 2. The thirteenth year. 3. Within a 
month after birth. Laennec found pneumonia, for the most part, to 
commence in the inferior lobes of the lungs; and this observation 
has been confirmed by Andral, who, in 80 cases, found the disease to 
attack the inferior lobe 47 times, the superior lobe 30, and the whole 
lung at the same time, 1 1.] 

Phenomena. — Like other acute diseases, pneumonia commences 
with shivering, followed by a hot stage, which is, in general, pretty- 
violent, unless in congestive inflammation, when coldness predomi- 
nates. There is more or less dyspnoea, and the number of respirations 
considerably exceed twenty in a minute, which may be taken as 
about the natural standard. The breathing is in some cases very 
laborious, but we must be careful, as Andral properly remarks, not 
to allow ourselves to be led astray by the account which patients 
give respecting this point, for often, when the respiration is short and 
hurried, they will assure us that they do not feel the least impedi- 
ment. Pain is not a well-marked symptom in inflammation of the 
substance of the lungs ; the patient complains rather of a tightness 
in the thorax; and when pain exists, it is, in general, dull instead of 
sharp. The cough is short, perpetual, and does not come on by fits; 



PNEUMONIA. 591 

it is dry at the commencement, and continues very distressing and 
obstinate. The expectoration is scanty, viscid, and discoloured, from 
an admixture of blood ; sometimes it is bright, like red currant jelly, 
but in general, it is rusty-looking, resembling brick dust intimately 
mixed with viscid mucus; it is so tenacious as to adhere firmly to 
the sides of the vessel into which the patient spits. [This kind of 
expectoration is characteristic of pneumonia.] It is very important 
to attend to the colour of the expectoration, because it assists us 
in determining, not only the nature of the disease, but also its extent 
and severity. The expectoration is sometimes, though rarely, fetid. 
A gangrenous odour is perceived when the disease terminates in gan- 
grene. 

The pulse is variable in many respects, and practitioners should 
be very wary in depending upon it, in the confident manner so gene- 
rally followed, and more particularly in pneumonia, which I have 
known to go on rapidly to a fatal termination, the pulse never ex- 
ceeding the natural standard. Sometimes, when the inflammation 
is most intense, it is observed to be extremely small. Morgagni no- 
ticed the uncertainty of the pulse in pneumonia long ago. Many 
suppose that recovery is rare, when the pulse beats more than 130. 
Andral makes this remark, and I have no doubt, from the milk-and- 
water practice which is too frequently adopted by French practition- 
ers, in inflammations of important organs, that they may find it so. 
I often perceive the pulse to rise both in frequency and force after 
bleeding, when the disease is fast subsiding; in many irritable con- 
stitutions it increases in frequency, in consequence of considerable 
depletion even when the disease is declining. 

With respect to the heat of skin, I have similar remarks to make ; 
for although in many cases it may be hot and dry, yet in others it is 
below the natural standard. 

The tongue soon, in the course of this disease, becomes parched 

and dark-coloured; a dry glossy tongue is always a bad symptom. 

It has been too frequently stated in books and in lectures, that the 

illy becomes livid and discoloured in pneumonia—- this is an 

error, being more a symptom of bronchitis than of inflammation of 

the substance of the lungs. 

Delirium occasionally takes place, but it is far from bein? a gene- 
ral symptom; when it occurs early, it denotes danger, [Metastasis 
of the inflammation from the lungs to the brain, is no unusual 
occurrence, the secondary affection thus becoming more dangerous 
than th<' primary one. Some of the worst cases of phrenitis I have 
ever seen have been <>f this kind. When the brain becomes affected 
the pulmonary symptoms are commonly much relieved, and in 
some instances entirely.] Mental aberration often occurs, however, 
ain-r acute diseases in the chest and abdomen have been Bubdued, 
particularly by extensive bleeding. It in general soon yields to the 
■m of opiates and stimulants prudently sdministered. 

Much misconception exists respecting position in affections of the 

i. It is pretty generally believed that patients prefer to lie on 

the affected side. This is very much the case in pteuritis, empyema, 



392 PNEUMONIA. 

and in single bronchitis; but in pneumonia, patients are generally 
found on the back, particularly in severe cases. 

In the very severe forms of pneumonia, in which a large portion 
of the lung is inflamed, together with extensive effusion into the 
air-passages; or in cases complicated with considerable local con- 
gestions; or in those which terminate in gangrene of the lungs — 
the powers of life quickly give way, attended by symptoms which 
are generally denominated typhoid. In truth, this form of the 
disease has obtained the name of pneumonia typhoides. There 
is, undoubtedly, such a form of pneumonia, but I object to the ad- 
junct typhoides, as expressing erroneous ideas of the pathological 
condition of the body. This form of pneumonia was very preva- 
lent during the war, among troops stationed in exposed situations 
along the coast, and in large garrisons, where the night-duty was 
severe. The soldiers were often seized with the disease when ex- 
posed as sentinels; — instead of walking about, they frequently stand 
shivering in their sentry-boxes, the surface continues long chilled, 
and, with a view to fortify themselves, and produce warmth, they 
are in the habit of drinking ardent spirits in considerable quantity. 
In the strongest subjects, I have seen the disease, in such circum- 
stances, run its course to a fatal termination in from forty-eight to 
sixty hours. 

Remissions of this complaint sometimes take place, and it is too 
much the custom, at such times, either to omit the necessary reme- 
dies, or to be too solicitous about supporting the strength. 

Stethoscopic signs. — The only certain test of the presence of 
pneumonia, is that derived from auscultation : and, in considering 
this part of the subject, the disease must be divided into stages. In 
the first stage, or that of invasion, the crepitous rale is heard distinct- 
ly; it resembles the noise which is produced by sprinkling finely 
powdered salt on the fire, or rubbing a lock of hair gently between 
the finger and thumb near the ear. This rale exists also in oedema 
of the lungs and pulmonary apoplexy, but these are distinguished 
from pneumonia by other symptoms. In this stage, the sound pro- 
duced by percussion does not differ from that of health. When 
complete solidification has taken place, neither the crepitous rale nor 
the respiratory murmur is heard ; but, in the sound part of the lungs, 
the respiration will be perceived louder than natural; — this is called 
by Laennec " puerile respiration." Laennec says, that broncho- 
phonism exists in certain cases, particularly if the inflammation be 
seated near the roots of the lungs, or in the upper lobes, in which 
places the bronchial tubes are the largest. In this second stage, 
percussion elicits a dull sound over the affected parts, unless the in- 
flammation be confined to a small central space in the substance of 
the lungs. In the third stage, when the infiltration of pus-like mat- 
ter begins to take place in the pulmonary tissue, the mucous rale is 
perceived to a greater or less degree, which Laennec supposes to be 
produced by the introduction of the fluid into the bronchial tubes; — 
when a large portion becomes softened, he calls it an abscess, and 
says that a very strong mucous or cavernous rale is perceived over 
its site, with pectoriloquism. 



[PNEUMONIA.] 593 

When resolution takes place before the disease has run into soli- 
dification, the crepitous rale becomes daily less perceptible, while 
the natural sound of respiration increases, and becomes gradually- 
more distinct; at length it is heard without the least crepitous 
sound. But if solidification have taken place, the cure is invaria- 
bly accompanied by the return of the crepitous rale, and then, as 
that declines, the respiratory murmur becomes more and more dis- 
tinct. 

I have thought it right not to be too minute in this description, by 
avoiding the varieties and combinations of these sounds, in the belief 
that they tend to puzzle the beginner. He may afterwards improve 
himself, and compare his observations with Laennec's statements; 
besides which, every professional man ought to possess Dr. Forbes's 
translation, which contains much additional matter. But it is my duty 
to express my fears, that few will ever arrive at that degree of per- 
fection which Laennec possessed in the detection of all the varieties 
which he has described. 

1 have seen several cases within these few years, in which pneu- 
monia existed in one lung, and severe bronchitis in the other; nay, 
they may exist in the same lung, which will of course mask the 
crepitous rale. 

Inflammation attacks the right lung more frequently than the left; 
it rarely alfecis both lungs simultaneously; the inferior lobe is much 
more frequently the seat of inflammation than other parts of the lung. 

Appearances on dissection. — On examining the lungs, or any 
portion of them, in the first stage of inflammation, they will be found 
red from the quantity of blood contained in the vessels of the part, 
and increased in weight. [This state is called congestion, or active 
hyperemia of the lungs. Whether the blood is confined to the 
blood-vessels, or is extravasated into the air cells themselves, is a 
question among pathologists; but it seems probable that the cells are 
tor the most part only compressed and not invaded, because they still 
crepitate (though in a diminished degree) under the finger. That tin; 
effusion, howe\ er, sometimes reaches the cells, and even the bronchi 
is unquestionable." It is generally of a deep red or pink-colour. 
I aiich, observes M. Andral, is certain, that hepatization ispto- 
duo 'l by a sanguineous congestion of the membranous parietea of the 
bronchia and air-cells, the effect of which is to dimmish or obliterate 
their cavities. This morbid condition may pervade an entire luttg, 
Of it may affeel certain lobules only, and these separated by sound 
structure. This variety is called lobular hepatization. In common 
with m is, it has occurred to me to see a portion of hepa- 

n only i ■ i" t m. Gdartinet, " we recognize it by 

crtpitalion, which seems to be merely the diminutive, aa it were, of the mucous >ai<- ; 
.-ifui ii ii | iii the bronchia, we can scarcely be- 

idmii tti.it ;t mix to re >>i air-fluid in Lhe smallest bronchi, giv< 

are merely the ultimate terminal iona of the bronchi, i 
i . tin-ri, .-ip- the seat of the crepitation in the iOm stage 

of pneumonia. Iflhl ect, it follows that Mi statssen- 

ttnllii man injlummat ion • •! I hi air-alls toAfiU lining m< mhr.tin secrete! :i llin.l ;il Inst 

>leni (<>r iln- colour oi Iron-rust) and finally purulent." 

/■ 



394 PNEUMONIA. 

tized lung, on being divided with a knife, dotted with numberless 
little whitish grains, which may readily be mistaken for tubercles; 
but these bodies are merely lymph which has been deposited in the 
vesicles, and minute bronchia during the progress of inflammation.] 

In the second stage, that of solidification, to which Andral applies 
the term softening, and Laennec hepatization, the diseased part 
will be readily broken down between the finger and thumb, which 
cannot be effected in the sound state, and the lung has lost entirely 
the crepitous feel ; and if put into water, it sinks at once to the bottom 
of the vessel. In the third stage, the lung is very heavy, and when 
cut into, is found to contain a great quantity of reddish or grayish 
fluid, which oozes from every point. 

[This fluid is genuine liquid pus, which pours out at every incision 
of the scalpel. The pulmonary structure is soft and granulated, and 
has a peculiar pale yellow colour, often mixed with red, giving the 
incised surface a mottled appearance. This condition of the lung is 
called by the various names of suppuration, yellow hepatization, and 
purulent infiltration. But if complete restoration of the lung does 
not succeed to the preceding morbid conditions, a fourth change takes 
place, which unlike the others, is not susceptible of resolution. This 
is called induration: it is characterized by a gray colour, more or 
less dark, though sometimes of a light ashy tint : it presents a dense 
dry consistence, often with a somewhat reticulated appearance de- 
rived from the remains of air-cells. When incised, it yields a sound 
not unlike that obtained by cutting a sponge with a knife.] 

The formation of an abscess in the lungs is a rare circumstance. 
I have seen one, or at most two instances of it. Laennec says he 
has seen it only five or six times. The granular appearance of an 
inflamed lung is best seen by tearing it : it seems to be agreed, by the 
best pathologists, that this is produced by the accretion of matter in 
the minute air-cells. The appearance of an abscess in the lungs is 
sometimes occasioned by an effusion of lymph, which takes place on 
the pleura, between the lobes; adhesions form round the circumfer- 
ence of the effusion, and when a section of the organ is made, upon 
a superficial view it is hastily concluded to be an abscess. 

A tubercular excavation is also frequently mistaken for an abscess: 
the history of the case, the appearance of the rest of the lung and 
that of the parietes, will put the inquirer right. The parietes of a 
cavern are solid, generally hard, lined with a false membrane, and 
there are probably portions of broken down tubercle. The large air- 
tubes contain a secretion, commonly of a gray or reddish colour. 

In cases of pneumonia, when the substance of the lungs near the 
surface has been the seat of disease, numerous ecchymotic patches 
are observed, and the contiguous pleura almost always suffers. 
Hence we frequently see false membrane, effusions of various degrees 
of consistence, and adhesions, which, if recent, will be easily sepa- 
rated, but if ancient, will be found firm, and sometimes, when par- 
tial, much elongated. 

It has been already mentioned, that inflammation of the substance 
of the lungs sometimes terminates in gangrene, but it is the least fre- 



PNEUMONIA. 395 

quent termination. Cases are recorded, where the whole lung was 
found in this state ; there are some in which one lobe only was af- 
fected, and in others it is still more partial. Dr. Bright has given 
several cases, accompanied by plates of the gangrenous appearances, 
in his excellent " Report of Medical Cases." 

[Gangrene of the lung is recognized by its extreme fetor. Some- 
times the sphacelus is gradually blended with the surrounding parts, 
the transition being marked by different grades of inflammation. In 
parts it becomes pultaceous or deliquescent, and a sanious fluid fol- 
lows every incision of the knife. In other instances there is an 
isolated gangrenous eschar, which becomes rapidly decomposed, and 
in favourable cases, makes its way into the bronchial tubes and is 
thrown off by expectoration. Recoveries from gangrene of this cir- 
cumscribed and limited character, are not unfrequeut. In some in- 
stances it affects the breath of the patient so as not to be mistaken, 
and considerable portions of the sphacelated structure are sometimes 
expectorated.] 

When the lungs have suffered from chronic inflammation, they, 
in the language of Andral, will be found in the hardened state. When 
cut into, the knife gives a sensation as if it were dividing cartilage. 
In this hardened condition, the substance of the lungs sometimes 
looks gray, at others red; when it is of a gray colour, it frequently 
lias the variegated appearance of granite. 

Treatment. — The lancet is to be used freely, and may be em- 
ployed later, with less injury to the patient than in bronchitis; but 
we must be guided very much by the stethoscopic siyns, by which 
much blood and strength may occasionally be saved to the patient. I 
trust no arguments need be used to prevent British practitioners from 
following the examples of the French, who bleed frequently, but in 
small quantities at a time; indeed, Laennec states that he rarely 
repeals venesection, except in the cases of patients affected with dis- 
eases of the heart, or threatened with apoplexy, or some other inter- 
nal congestion; and when he does bleed, he directs from eight to 
sixteen ounces 10 be taken from the arm, and even boasts of curing 
pneumonia without blood-letting. (Page 250.) 

Even on tins side of the Channel, bleeding is not always followed 
a^ it ought to be practised. Dr. Mason (iood, (at p. 43(j, vol. ii.,) in 
treating of pneumonia, says, « In this case the bleeding should be 
prompt and copious, at least to eighteen or twenty ounces, and re- 
peated twelve hours alter if necessary." I object strongly to this 
recommendation, both as to the quantity of blood to be drawn, and 
the long interval between the bleedings; but the reader is referred to 
my observations on that Bubjecl in another part of the work. 

Late in the disease, bleeding must be used in small quantity, and 
with the greatest caution. The great use of auscultation in treating 
pneumonia, is, that in general, not only is the practitioner accurately 
informed with regard to the extent of the disease, but he is told if 
the sanative process have commenced ; when bleeding is, to say the 

least Of it. a doubtful remedy, ami, in many cases, may do harm, by 

interfering with the powers of the constitution. Nevertheless, I am 



3S6 PNEUMONIA. 

persuaded, from experience in treating the disease, and from exami- 
nations after death, that much more mischief is done by bleeding too 
little than by bleeding too much ; but I am not an advocate for the 
heroic practice of taking seventy or eighty ounces of blood at one 
operation — the largest bleeding I can boast of was fifty-six ounces. 
In general, if the operation be properly performed, thirty or thirty- 
five ounces will suffice, but the patient should be seen again in the 
course of two or three hours.* 

I have the history of a case before me, in which one hundred and 
ninety-two ounces were taken from one individual ; but I am per- 
suaded, that if he had lost two-thirds less, it would have been better 
for him. Several months afterwards he was weak and miserable, 
and it appeared very doubtful that he ever could regain his health. 
On one occasion, early in life, I very nearly lost a patient, from whom 
I had taken, at different times, in the course of four days, one hun- 
dred and twenty ounces of blood, but who recovered after the exhi- 
bition of stimulants. Within the last fifteen years, I have seen several 
cases where considerable injury had been inflicted by very large 
bleedings, the medical attendants having allowed themselves to be 
misdirected by the continuance of dyspnoea, which increased after 
each abstraction of blood. It was evident that this was owing to a 
want of sufficient blood in the system. In one instance, the patient 
was on the brink of the grave, with a pale sunk countenance, and 
cold extremities: the strongest stimulants were administered, along 
with large opiates. All these cases eventually recovered. 

Antimony is of essential use in the treatment of pneumonia; but 
I would reverse the rule laid down by Laennec, and state that it is 
to be used as an auxiliary remedy only. Cullen, (in the 371st para- 
graph,) in alluding to antimony, says, that he has found it useful to 
exhibit nauseating doses, and in a somewhat advanced stage of the 
disease, that such doses proved the best means of promoting expec- 
toration. The Italian physicians, and particularly Rasori, first exhi- 
bited the emetic tartar in very considerable quantity, as a cure for 
inflammatory diseases. Rasori, it would appear, gives twelve grains 
during the first day, and as much during the night ; if the disease be 
already much advanced, he gives forty or sixty grains during the 
twenty-four hours, and goes on increasing the dose, till it amounts 
to several drachms. For much interesting information on this sub- 
ject, the reader is referred to a long note by Dr. Forbes, in his trans- 
lation of Laennec, p. 263. 

Laennec, who adopted the Italian practice in France, immediately 
after a small bleeding, gave one grain of tartar-emetic in three ounces 
and a half of fluid, which he repeated every second hour for six times. 
He then omitted the medicine for seven or eight hours, if the symp- 
toms were not urgent; but if the oppression became great, with affec- 
tion of the brain, or if both lungs or one whole lung were attacked, 
he continued the medicine uninterruptedly, until an amendment took 
place, indicated by the stethoscopic signs. " Sometimes, even, par- 

[* In some parts of the United Stales this will be considered a very free use of the 
lancet. See addenda at the end of this chapter.] 



PNEUMONIA. 397 

ticularly when most of the above-mentioned unfavourable symptoms 
are combined, I increase the dose (says he) of the tartar-emetic to a 
grain and a half, two grains, or even two grains and a half, without 
increasing the quantity of the vehicle. Many patients bear the medi- 
cine without being either vomited or purged." (Translation, p. 
251.) Indeed, it is an extraordinary fact, that the more severe the 
disease the less visible effect has antimony on the patient. This 
observation applies not only to pneumonia, but to bronchitis, in which 
very large doses do not produce nausea or vomiting, and which it is 
very difficult to bring about by any means. My experience in the 
use of antimony, and the result of the experiments which are pub- 
lished in the Lancet, (vol. ii, p. 536,) lead me to conclude, that vomit- 
ing is more speedily produced by a small dose dissolved in a large 
quantity of water, than by a large dose of the drug mixed with a little 
sugar ; but in the latter case the nausea is more severe, and of longer 
continuance than in the former. Laennec states that its most con- 
stant effect is the rapid resolution of inflammation, and sometimes 
the equally speedy absorption of the inflammatory effusion. The 
latter effect is proved in the case of Pemberton, the subject of my 
second experiment, who was affected with "induration and enlarge- 
ment of the testicle, which was of a scirrhous hardness." His first 
dose of the medicine was twelve grains, in half an ounce of water, 
taken upon an empty stomach: vomiting was not produced for fifty- 
five minutes. On the following day, the report states that the en- 
largement of the testicle was found to be diminished about one-third. 
In some days afterwards, he again took twelve grains in an ounce of 
the decoction of bark : vomiting did not take place till the expiration 
of an hour. Again he took, some time after, twenty grains in a little 
sugar, and suffered much less pain and nausea from this quantity 
than during the preceding experiments. On the following day, the 
report states, that "the enlargement of the testicle continues to de- 
crease;" in a short time it was found to be considerably reduced, 
and was soon quite cured. This man had been many months on the 
sickvlist; the disease had previously resisted all the usual remedies, 
and the question of extirpation was agitated. 

I have no faith in digitalis, in the ordinary doses, at least during 
the acute inflammatory stage. Blisters will be found useful, under 
the Rime restrictions as described in bronchitis. I have seen the best 
effects from opiates, during the decline of the disease, in allaying 
irritability and violence of the cough, os well as bv producing sleep. 
Formerly great objections were entertained against the employment 
of purgative medicines in this disease; but these are now happily 
removed. It is certainly necessary to keep the bowels open; for 
Which purpose I generally give a smart dose of physic immediately 
after the first bleeding, and some boms before the exhibition of the 
tartrate of antimony, and assist its operations by means of injections. 
Subsequently, if the antimony do not operate upon the bowels, 
evacuations should be produced daily by injections, as medicine 
taken by the mouth will not be retained by the stomach. 

The regimen, il is almost unnecessary to remark, should be strictly 
antiphlogistic; and with a view to prevent vomiting during the anti- 
;i 



398 [PNEUMONIA.] 

raonial treatment, as little liquid as possible should be allowed. 
During recovery from all acute diseases of the chest, visitors should 
be excluded, as talking, even in an under tone, is injurious to the 
patient. 

[The treatment of pneumonia in the United States is, for the most 
part, of a less depletory character than that advised in this chapter. 
Although with us the disease is violently inflammatory, the expe- 
rience of both public and private practice is in favour of a more 
moderate use of the lancet than that here recommended. From 
fourteen to twenty ounces of blood may be at first taken, and it is 
often necessary to repeat the venesection in a few hours ; but in 
very many cases, if the general bleeding be followed at once by free 
cupping over the affected part of the chest, and if a large blister be 
applied as soon thereafter as the condition of the patient will allow, 
the disease will yield without difficulty. Such has been the fact 
even in our Philadelphia Hospital, where pneumonia is very preva- 
lent in the winter and spring, and occurs in miserably broken con- 
stitutions. Mercurial purgatives, with antimonials, in small doses, in 
mucilaginous drinks, and the occasional addition of opiates, are the 
principal adjuvant remedies. 

M. Louis has expressed his conviction that the value of vene- 
section has been overrated in pneumonia, and that blisters are use- 
less in most acute diseases of the chest. He sums up the result of 
his observations as follows: 

" 1. That blood-letting has a happy effect on the progress of 
pneumonitis; that it shortens its duration ; that this effect, however, 
is much less than has been commonly believed ; but that patients 
bled during the first four days recover, other things being equal, four 
or five days sooner than those bled at a later period. 

" 2. That pneumonitis is never arrested at once by blood-letting ; 
at least, not on the first days of the disease. If an opposite opinion 
is maintained, it is because this disease has been confounded with 
another, or because, in some rare cases, the symptoms rapidly dimi- 
nish after the first blood-letting. But then the local symptoms, 
crepitation, &c, for the most part, continue to be developed not the 
less for this evacuation. 

" 3. That vesication has no evident influence upon the progress of 
pneumonitis; and that it may be dispensed with in the treatment of 
pleurisy and pericarditis, occurring in healthy subjects."* 

However curious these results are, they have not been derived 
from a sufficient number of cases to warrant their adoption; and it 
may be remarked that M. Louis's objections to blisters in acute pul- 
monary affections, will apply equally well to their use in all acute 
diseases. My own experience, though not susceptible of the same 
numerical analysis as his, has led me to very opposite conclusions; 
and I still regard vesication as one of the most important adjuvants 
in the treatment of acute diseases of the chest. 

Pneumonia of children. — The lobular form of pneumonia is 
characteristic of infancy and early childhood, anterior to the period 

[* Researches on ihe Effects of Blood-letting, &c, by P. Ch. A. Louis, with preface 
and appendix, by James Jackson, M. D. Boston, 1836.] 



[PNEUMONIA.] 399 

of second dentition. "The peculiar anatomical character of the 
disorder," observes Dr. Gerhard, " is that the inflammation is diffused 
through several scattered points, which are attacked at the same time, 
or nearly at the same time. These points are single lobules, or parts 
of lobules, divided by the cellular tissue. The tissue is first con- 
gested, and afterwards inflammation sets in, and as the disease ex- 
tends from point to point, it passes along the posterior portion of the 
lung, according to the ordinary laws of pneumonia, but, as it were, 
in a scattering way, attacking several lobules at the same time."* 
The treatment of the pneumonia of children must, of course, be the 
same, in general principles, as that of adults; but it is important, in 
addition, to change the position of the patient frequently, in order to 
prevent the blood from gravitating to the posterior or depending por- 
tions of the chest. We thus obviate one of the causes of congestion 
and consequent hepatization.] 

[♦ Notes to Tweedie's Library of Practical Medicine, ii. p. 352.] 



CHAPTER IV. 
PLEURITIS.— PLEURISY. 



Phenomena. — As in other acute diseases, pleuritis is generally 
ushered in by a cold stage of greater or less severity. The patient 
complains of fixed pain in the side, over which he can place his 
finger, which is described as a stitch, catching and interrupting his 
breathing every now and then, particularly when he fills his lungs 
beyond a certain extent. The pain is sometimes so severe, that the 
patient, in describing it, says it is like a stab with a sharp instru- 
ment. In pleuritis, the breathing is difficult and anxious; but it is 
short, and not so heavy and oppressed, in the first instance, at least, 
as in inflammation of the other tissues. There is also cough, which 
aggravates the pain very much: the expectoration is thin and 
watery, very different from that in pneumonia and bronchitis. The 
pulse, generally speaking, is quicker and harder, and the heat of the 
skin is more intense than in pneumonia and bronchitis; but inflam- 
mation of the pleura, the most intense and extensive, may take place, 
and terminate fatally, without being detected by these symptoms. 
At present, I may remark, with regard to the heat of skin, that it is 
greatest over the thorax in pleuritis, and very often I have felt it 
much increased over the seat of the disease, at which point external 
pressure is much complained of. The tongue, however much furred 
it may be, soon becomes dry. The urine is scanty and high-coloured. 
The functions of the brain are also sometimes disturbed. 

[When both the pleura are simultaneously affected, the disease is 
called by the French pathologists a double pleurisy, which, accord- 
ing to the extended observations of M. Louis, is a very rare dis- 
ease, especially in persons not affected with tubercle ] 

There is a painful affection, commonly ascribed to the intercostal 
muscles, termed pleurodynia, which gives rise to all the symptoms 
above described, and it is often impossible to determine the one dis- 
ease from the other except by auscultation and percussion. A 
symptomatica! physician may now and then guess right, but it is only 
to be considered as a guess. Three such cases occurred to me within 
a very short space of each other, one only of which proved to be 
pleurisy, although, from the slightness of the symptoms, and the 
character of the patient, who was always complaining of trifles, I 
least expected to find it. Dr. Ferriar, (at p. S6 of his 2d vol.,) states 
the case of a boy, who died from extensive inflammatory action of 
the pleura, and effusion into the pericardium, who, nevertheless, had 



PLEURITIS. 401 

"no cough, no difficulty of breathing, nor pain in his breast, and I 
could not find, (says Dr. Ferriar,) from the most careful inquiry, that 
he had ever made such complaints. There was great paleness over 
the whole skin. He was torpid ; without delirium, or the symptoms 
of oppression common in typhus." In his observations upon this 
case, he states, " In this case, an active inflammation through the 
whole extent of the pleura, producing exudation and adhesions, was 
not indicated by any symptom during the continuance of the com- 
plaint." 

Stelhoscopic signs. — In pleurisy, these signs are of less import- 
ance, in directing the treatment, than in pneumonia and bronchitis, 
because there is no particular sound elicited by the stethoscope, in 
pleurisy, till the inflammation has produced effusion. But great 
advantage is, nevertheless, obtained from the negative proof afforded 
by auscultation, which will inform us if either of these two diseases 
exists. Independently of this, however, the stethoscope is of use in 
pleuritis, by informing us when effusion really exists, which, it is 
admitted, cannot be done by the ordinary signs. 

In the early stage of pleuritis, the respiratory murmur is less dis- 
tinct, but not otherwise changed, over the site of the diseased part. 
When effusion takes place, the sound in the lower part of the chest 
becomes dull, and when the patient is desired to speak, his voice is 
heard through the stethoscope, at the diseased part, small, sharp, and 
very tremulous, to which Laennec has given the name egophony* 
When the effusion is very extensive, and in considerable quantity, 
the sound elicited by percussion is very dull, and respiration is not 
heard, unless at points where old adhesions exist, which prevent the 
lungs from being compressed and forced away from the ribs. On 
examining the naked chest, when there is great effusion, that side of 
the thorax is perceived to be the largest ; the ribs are found more 
distant from each other, and more fixed during respiration, than on 
the healthy side. Egophony exists in hydrothorax also; but this 
is of little consequence, as the general history of the case, and local 
symptoms, must always be appealed to, and weighed as necessary 
i ih.' evidence in each case. 

It mnsl be recollected that pneumonia and pleuritis frequently 
coexist; but neither 18 that circumstance of much consequence, 
being both inflammatory diseases, and requiring the same general 
remedies. 

Appearance* mi dissection. — The pleura, when inflamed in the 
tage, bHows b greal number of red points, which are sometimes 
produced by slighl eechymosis in the cellular membrane, beneath the 
pleura; red vessels are also frequently observed, and the spaces be- 
tween iii'- vessels, and between the puncise, appear natural. The 
pleura is rarely found thickened, although it may appear to be in 

I • 'I' also by it^ nasal and cracking resonance, no) unlike 

ihebl lj marked, il la distinctly metallic, jar- 

r m lt and muffled; i* nrncbronous with the articulation of each word, or follows il 

immediate!) like a thrill echo of natural resonance, [l conveys the idea, of a distant 

and does not appear to u ethoscope, but rather to flutter tremn* 

P D p, 78.] 

31' 



402 PLEURITIS. 

that state, the deception arising from the disposition of coagulable 
lymph, the removal of which shows the pleura without alteration of 
structure. It has frequently occurred to me, in chronic pleuritis, to 
be able to separate what appeared to be two and even three layers 
of new membrane. There is often found extensive effusion of a 
serous fluid, like whey, exactly similar to that seen in the abdomen in 
peritonitis. [Effusion does not necessarily follow inflammation of 
the pleura; but there is sufficient evidence that when it does occur, 
it is often simultaneous with the inflammation itself. This fact was 
first pointed out by Laennec, and has since been confirmed by all 
pathologists. It is not unusual to find a large quantity of water 
in the chest after active pleurisy has continued but three or four 
hours.] Sometimes we find the lungs attached to the pleura lining 
the general cavity, by an intermediate deposition of lymph ; when 
recent, the parts are easily separated, and there is the best evidence 
for believing that the new matter becomes organized. Occasionally 
(particularly in chronic pleuritis), we find both the pleura pulmoualis 
and costalis inflamed, and much thickened by the deposition of 
lymph, with or without an effusion of serum mixed with lymph, 
which resembles thick pus ; masses of lymph, weighing half an ounce 
or more, are sometimes found in the bottom of the cavity. If there 
be no old adhesions, and the effusion be large, the lung, greatly com- 
pressed, will be found lying close to the spine, perhaps without any 
alteration of structure. Mortification is one of the rarest results of 
inflammation of the pleura. Ulceration is also an unusual termi- 
nation, but I have seen two instances of this lesion ; the ulcerations 
were extensive, and affected not only the pleura pulmoualis, but the 
pleura costalis, as well as that part which forms the mediastinum. In 
one case, of which 1 have a very beautiful representation, six large 
ulcerated spots were observed upon the anterior surface of the right 
lung, one of which was two inches in length, and above an inch in 
breadth, occupying almost a regular oblong space, while the rest ap- 
proached to the circular form. There were eight or nine ulcerations 
on corresponding parts of the pleura costalis, of an oval shape — one 
very large ; there was also one above two inches in length on the 
mediastinum. The pleura was very vascular, and the margin of 
each ulceration was red, thickened and somewhat indurated ; no 
trace of the pleura could be perceived on the ulcerated surfaces, ex- 
cept here and there a small ragged portion was met with. The ulcers 
were covered with a puriform matter. The lung was somewhat 
compressed, and, on making incisions through the ulcerated parts, its 
substance was found to be red and hard ; a state of the organ which 
extended to no great depth, in some places not greater than a line, 
and nowhere more than about the third of an inch ; the rest of it 
being engorged. In this case, which I did not see till within a few 
hours of the fatal termination, no suspicion was entertained of the 
true nature of the affection ; the treatment was conducted by two 
physicians, for whose talents and practical experience I entertain 
great respect ; but it may be mentioned, that neither of them used 
the stethoscope. At first it was supposed there was some pulmo- 
nary affection, for which the lancet was used; but very soon the vital 



PLEURITIS. 403 

powers began to sink, when the disease was denominated typhus 
fever, and treated accordingly. 

A case of pneumonia, complicated with pleuritis, presented itself 
to me since the publication of the last edition, which threw some light 
upon this very unusual termination of inflammation of the pleura. 
The case was very severe; the subject of it, a soldier on furlough ; 
the cause, exposure and drinking ardent spirits to great excess. 
When he fell under my care, the disease was of ten days' duration, 
and he was sent by his friends to the Royal Ordnance Hospital, that 
he might enjoy the comforts of such an establishment. 

On dissection, both lungs were found universally solidified, and 
the pleura inflamed. There were numerous and extensive ecchy- 
motic spots on the surface of the lungs, as well as on the pleura cos- 
tal is, and there were large masses of lymph effused here and there. 
There were likewise several puriform collections between the pleural 
surfaces. On laying these freely open, pure pus was found in two 
or three places; in others, a small quantity of fluid or coagulated 
blood, mixed with pus .In these places there were loss of substance, 
and an appearance of ulceration, which would have been more com- 
plete had the patient lived a few days. 

[When the secretion of coagulable lymph is accompanied with an 
effusion of red blood, it constitutes the hemorrhagic pleurisy of 
Laennec. 

Tins is a troublesome complication ; because, as Dr. Williams ob- 
serves, the colouring matter in no way contributes to the formation of 
texture, and must be absorbed before perfect organization of false 
membranes can be effected; and to this cause he mainly attributes 
those fibrous or fibro-cartilaginous structures of the pleura, which will 
be noticed at the end of this chapter, which are slow in formation, 
and unyielding in texture.*] 

Treatment. — Little need be said respecting the treatment of pleu- 
risy, farther than that bleeding is to be had recourse to repeatedly and 
copiously. Leeches applied over the seat of the pain are often of 
very singular benefit; in some cases no other means of detracting 
I will be required. Antimony may in; employed, together with 
ives and an occasional opiate. The antiphlogistic regimen is ab- 
Bolutely required, and blisters are often useful. 

When called to a case of pleurisy, a careful investigation should 
be made to ascertain whether the disease may not have advanced 
already to its extreme termination. If so, bleeding may do much 

mischief, and we shall be obliged to place our hopes of safety on 

- >me of tie; other means recommend d in inflammatory diseases, 
more particularly on blisters, digitalis, antimony, opium and calomel. 
In pleurodynia, a warm bath, and a dose of Dover's powder, will 
in general, be sufficient to mitigate the violence of the pain ; a ban- 
d tightly round the thorax, is serviceable, by preventing 
the motion of the ribs, A good practical man, however, will alwaj s 
!"• found to act on the safe I when m doubt, be makes n a 

rule to give the patient th<' benefit of that doubt, by employing the 
means required in the no i ere disease. 

[• Physical Signs of Diseases of the Langs and Pleara, p.l8&] 



404 CHRONIC PLEURITIS. 

Dr. Rush, in considering the probability of a connection between a 
morbid excitement at the neck of the bladder, and the safety of more 
vital parts of the body, states, that ''the idea of this connection was 
first suggested to me four and twenty years ago, by the late Dr. James 
Leiper, of Maryland, who informed me he had sometimes cured the 
most dangerous cases of pleurisy, after the usual remedies had failed, 
by exciting a strangury, by means of the tincture of Spanish flies 
mixed with camphorated spirit of wine."* 

I have only further to state, that relapses, in all inflammatory com- 
plaints of the chest, are generally to be attributed to improper ex- 
posure, imprudence in diet, and to the too early exertion of the voice; 
therefore it is always safer to continue the restrictions, and particu- 
larly the antiphlogistic regimen, a day or two longer, than to allow 
liberties to be taken a single day too soon. The practitioner finds 
himself often foiled on these points, by the imprudence of patients 
and attendants; in such circumstances, it is an excellent plan to keep 
the patient slightly under the influence of antimony, which will pre- 
vent the generality of people from feeling much inclination to eat, 
speak, or sit up. 



CHRONIC PLEURITIS. 

According to Laennec, there are three kinds of chronic pleurisy: 
— Is/. That which is chronic from its origin ; 2d. Acute pleurisy 
becoming chronic; 3d. Pleurisy complicated with certain organic 
productions on the surface of the pleura. I shall follow a different 
plan in this work, and first describe the chronic pleurisy, which ter- 
minates in empyema, and afterwards that which terminates in 
permanent contraction of the chest. 

Empyema. — This term implies the existence of matter in the 
chest, the effect of chronic pleurisy, or the bursting of a pulmonary 
vomica into the cavity of the pleura; of this last affection I shall 
speak, after treating of phthisis. Whether the empyema be produced 
by a pleurisy which was chronic from the first, or considered as the 
termination of the acute form of the disease, the effect is the same — 
there being generally dyspnoea, the breathing being easier in the 
erect posture ; dry tickling cough; hectic fever; enlargement of one 
side of the thorax when compared with the other; the intercostal 
spaces being increased ; the patient cannot lie except on the diseased 
side: sometimes fluctuation may be felt. This form of the disease 
appears to have been well known to Hippocrates, although he con- 
founded it with pneumothorax.! 

Stethoscopic signs. — Percussion gives a dull sound, and the re- 
spiratory murmur is not heard, except in the region of the spine, 
which will be puerile on the other side ; but here we must recollect 
that the effusion may be double, although this is a rare circumstance. 

* Medical Inq. and Observ. vol. iv. p. 25. 

t An excellent paper on Empyema, &c, by Dr. Duncan, jun., in ihe 93d No. of 
the Edin. Med. and Surg. Journal. 



[CHRONIC PLEURITIS.] 405 

Treatment. — When effusion is discovered, the sooner the chest is 
tapped the better, as remarkable recoveries have taken place, show- 
ing that there is still some hope. There is, however, some difference 
of opinion respecting the propriety of drawing off the matter all at 
once, or by degrees. Although my experience on this subject is very 
limited, yet I am induced to believe that the more quickly the matter 
is removed the better. A most interesting case, successfully treated 
by Dr. Pitcairn, of Edinburgh, is recorded in the 2d vol. Edin. Med. 
Chir. Transactions, p. 229. During the recovery, we should be on 
our guard to prevent, by means of regimen, a renewal of the inflam- 
mation. Instances are upon record, in which the matter found its 
way out of the chest through the parietes, and also through the 
bronchial tubes. 

The other kind of chronic pleurisy to which I wish to allude, is 
that which leads to permanent contraction of the chest. The deform- 
ity is readily perceived on looking at the naked chest ; the affected 
side is found to be narrower than the other, and the length is equally 
diminished in consequence of the ribs being drawn closer to each 
other. The muscles are also much smaller, which adds to the dis- 
proportion of the chest. [It will mostly also be observed, that in 
proportion as the ribs are retracted in front, the corresponding 
scapula projects beyond its fellow.] The patient leans to the affected 
side ; in many cases so much so, as to make him appear as if he had 
an affection of the spine : this happened in Dr. Pitcaim's case above 
quoted. 

Laennec states that it was long before he had an opportunity of 
ascertaining to what cause the contraction of the thorax was owing, 
which he at last discovered to depend on fibrocartilaginous adhe- 
sions between the pluera pulmonalis and costalis. He nevertheless 
thinks that a degree of contraction is produced by the common cellu- 
lar adhesions when very extensive; for he states, that in every case 
wherein he found one lung adhering throughout, by means of a 
pretty copious cellular tissue, he has always thought that side of the 
dust narrower than the other. I have seen several cases of con- 
traction of the chest from this cause; one where the contraction was 
in the l<'l'i .side, and evidently connected with some affection of the 
heart and pericardium. Some years ego, when accidentally at Chi- 
ter, Dr. Forbes, the accomplished translator of Laennec's work, 
was kind enough to take me" to visit a patient who was affected in 
this manner, and in whom the contraction succeeded, if I remember 
rightly, to a severe attack of acute pleurisy.* 

| Contraction of the chest also occurs independent of adhesions. 
Thus, when pleurisy has been attended by copious effusion, the 
fluid presses til': lung upwards, and more or less impedes its func- 
tions. If, after this condition has lasted a considerable time, absorp- 
tion takes place rapidly, the lung does not expand with sufficient 
rity to fill the threatened vacuum, but tin; ribs, on the contrary, 
collapse upon the lung. Tin: consequent deformity is often obli- 
teratCjd during the growth of children, but is for the most part 

uretrietable in adults. 

• ii r.ix will be treated of in the chapter on Dropsy, in the Bd vol. 



406 [CHRONIC PLEURITIS.— PNEUMOTHORAX.] 

The lesions usually met with in chronic pleurisy, besides those 
already described, consist chiefly of adhesions, which assume a 
variety of forms, viz : 

1. Thread-like cords and flattened bands, passing from one surface 
of the pleura to the other, diaphanous, and sometimes more than 
two inches in length. Their characters closely resemble those of 
cellular tissue. 

2. In some rare instances these cords attain a great thickness, and 
still more rarely enclose adipose matter. 

3. There is a false membrane of fibro-cartilaginous structure, re- 
sulting from long-continued irritation of the pleurae; it is formed be- 
tween the latter by successive deposits of lymph, and even attains an 
inch in thickness. Its colour is white or grayish, with a tinge of yel- 
low. This substance sometimes assumes the spheroidal form on the 
free surface of the pleura, and may be mistaken for tubercles.] 



[PNEUMOTHORAX.] 

[This name is given to a collection of air in the cavity of the pleura, 
and may arise from various causes. 

1st. It may be a simple secretion of air into the thoracic cavity, 
precisely analogous to what takes place in the abdomen, constituting 
tympanitis. 2d. It may result from chronic serous effusion ; for the 
lung, having been long compressed, does not expand again, and the 
water, on being absorbed, is replaced by air. 3d. The common cause 
of pneumothorax is a perforation of the pleura, permitting the direct 
escape of air into the cavity of the thorax. Sometimes both air and 
water are present at the same time ; a complication which is termed 
hydro-p neu mo thorax. 

In these conditions, the sound on percussion is greatly increased in 
clearness and duration, and is essentially tympanitic; while the 
stethoscope detects the respiration, weak in proportion to the com- 
pression of the lung, and sometimes wholly absent. The vocal re- 
sonance is rarely suppressed altogether in pneumothorax; but it is 
often greatly diminished. In hydro-pneumothorax we find the signs 
of pleuritic effusion and of pneumothorax ; the former at the lower, 
the latter at the upper part of the affected side.* 

The treatment of these morbid conditions will be inferred from 
what has already been said of the different forms of pleurisy; but 
simple pneumothorax may exist for years without any obvious dis- 
tress to the patient, and without being available to remedial agents.] 

[* Walshe.— Physical Diagnosis of Diseases of the Lungs, p. 150.] 



CHAPTER V. 
HEMOPTYSIS. 



This term signifies a discharge of blood from the air-passages, 
which occurs principally under three forms: — Is/. A general exhala- 
tion from the mucous surface of the bronchial tubes. 2d. From 
apoplexy of the lungs. 3^/. From an erosion of a blood-vessel in a 
tubercular excavation in the lungs, and which falls to be considered 
with phthisis pulmonalis. [To these may be added a fourth form, 
which takes place from the granulations of abscesses.] 

The first variety is the most common, and is not generally 
attended with much danger. It frequently attacks women at the 
monthly periods, when the menstrual discharge is more scanty than 
usual, or is entirely suppressed ; girls are often so affected at the age 
of puberty, immediately before the catamenia should appear; but 
the male sex are not exempt from it. I have seen it appear in men, 
upon the sudden drying of an old sore, or the disappearance of a 
long-standing eruption; it sometimes succeeds to mental affliction. 
The discharge is generally preceded by some constitutional disturb- 
ance ; the bowels are found out of order; the tongue foul ; the patient 
his passed somewhat restless nights, with more or less fever, and 
feels must comfortable in the half-erect posture. At last there is 
OOUgb, which is often constant and distressing, with more or less 
dyspnoea, particularly when moving about. The pulse varies much. 
irding to the age and constitution of the patient, and the period 
ofth' : 'hi generally it is quick and bounding. I have com- 

monly Been this form of the disease creep on insidiously; but at the 
same lime it must he confessed that a bloody expectoration sometimes 
takes place suddenly, immediately after the occurrence of cough and 
dyspnoea. The expectoration has a peculiar appearance: it resem- 
bles red currant jelly— sometimes not so much tinged, but like a 
mixture containing different proportions of apple-jelly with red cur- 
rant ; it is sometimes copious, but in general the quantity discharged 
is moderate. Sometimes, however, the expectoration is of a mixed 
kind, small me gulated blood being observed. Occasion- 

ally, indeed, the discharge is quite bloody, but moderate in quantity, 
and very frothy ; hut in some eases, pure blood in large quantities is 
discharged. On all occasions, it is much increased by every exer- 
tion, eithe! of the body or the voice. According to Laennec, the 
chest is perfectly sonorous. On applying the ear, the crepitous rale 



408 HEMOPTYSIS. 

is not heard as in pulmonary apoplexy ; but there exists a mucous 
rale, which is more or less extensive, according to the quantity of 
blood effused into the air-passages. 

Appearances on dissection. — I have never been present at a 
dissection of a person who died of this form of the complaint ; but 
Laennec states, that, "on examining subjects who have died of 
bronchial haemorrhage, or while labouring under it, more or less 
of coagulated or fluid blood is found in the bronchia. On the sur- 
face of the coagula, we sometimes observe fibrinous concretions in 
the form of polypi. The mucous membrane is commonly a little 
softened, and impregnated or tinged with blood through its whole 
depth."* 

Treatment of the first variety. — This is, in general, very simple. 
Blood-letting is not necessary, unless the patient be plethoric, or 
there are marks of an irregular determination of blood, which we 
wish to remove, when one bleeding will, in general, suffice. The 
leading points to be attended to are the following: — Perfect rest, 
silence, abstinence from every stimulant ; a very small quantity of 
food is to be taken at a time. The patient should be placed, if pos- 
sible, in a large, cool apartment, with light clothing; and a pretty 
smart action kept up on the bowels, by means of frequently repeated 
laxatives. If, however, the discharge still continues, with a strong 
pulse, small doses of the tartrate of antimony are to be used, to pro- 
duce some degree of nausea; but the most potent remedy with 
which I am acquainted, is the acetate of lead, which I commonly 
prescribe in such cases, in doses of two, three or four grains every 
third or fourth hour; but I never use it till the plethora is considera- 
bly reduced. A great many other astringents have been employed, 
as sulphuric acid, alum, kino, the bark of the pomegranate, and the 
ratany root. 

[To these may be added the popular remedy of common salt. 
Another extemporaneous resource is the oil of turpentine, of which 
10 or 20 drops may be given in a wineglass of sweetened water, 
and repeated every 20 minutes until relief is obtained. The mil- 
riated tincture of iron will also be found sometimes efficacious.] 

The second variety, or that which proceeds from pulmonary 
apoplexy, is marked by a greater degree of haemorrhage, which is 
sometimes so violent as to resist all medical treatment. The patho- 
logy of this variety of haemoptysis, was, as Dr. Forbes remarks, 
entirely unknown before the publication of the first edition of Laen- 
nec's work, although some obscure notices had been given by others 
before that period. 

Symptoms. — This disease is, in general, preceded by symptoms 
common to haemorrhages from any other parts of the body, such as 
chilliness — cold extremities, followed by flushes of heat and redness 
of the cheeks, headache, quick and extremely hard pulse— palpita- 
tion of the "heart, praecordial oppression. The discharge from the 
lungs is attended with dyspnoea — suffocating feeling in the chest, 
sometimes, according to Laennec, with great pain— oppression at 

* Forbes's Translation^. 128. 



H.EMOPTYSIS. 409 

the praecordia — sense of rawness of the throat, and a saltish taste in 
the month. The expectoration consists of bright and frothy, or 
black and clotted blood, sometimes intermixed with saliva or a little 
mucns. 

The pulse is frequent and full, with a feeling of vibration: the heat 
of skin is not considerable; sometimes I have seen profuse perspira- 
tion. The spitting of blood is copious, and returns by fits, with 
cough, oppression, anxiety, intense redness or extreme paleness of 
the face and coldness of the extremities. When the haemorrhage is 
very great, says Laennec, " it comes on sometimes with a very mo- 
derate degree of cough, and is accompanied by a convulsive eleva- 
tion of the diaphragm, like that which takes place in vomiting." 
This accounts for the expression, " vomiting of bloody which is 
used by most persons who have suffered in this way. He thinks 
that part of the discharge very often comes from the stomach, and 
that haematemesis frequently coexists with haemoptysis. Laennec 
has known ten pounds of blood lost in this manner in .forty-eight 
hours, by a young man who died under the haemorrhage. In other 
cases lie has seen about thirty pounds lost in a period of fifteen days ; 
but, in general, the discharge does not exceed 12 or 15 ounces in 
twenty-four hours, and in some cases, not three or four. 

Percussion, in general, gives no information. Auscultation, how- 
ever, furnishes us with the two principal signs of pulmonary apo- 
plexy — the want of the sound of respiration over a circumscribed 
space, which may be more or less extensive, and a crepitous rale 
round this space. 

Appearances on dissection. — Having had comparatively but few 
opportunities of observing these appearances, I shall take the liberty 
of copying Laennec's account. " Some part of the pulmonary sys- 
tem has undergone great changes, being indurated to a degree equal 
to the most complete hepatization. The induration, however, is very 
different from the inflammatory affection of the lungs distinguished 
by this term. It is always partial, and scarcely ever occupies a con- 
siderable portion ol the lungs; its more ordinary extent being from 
0O6 to lour cubic inches. It is almost always very exactly circuin- 
■ d, the induration being as considerable at the very point of ter- 
mination as in the centre. The pulmonary tissue around is quite 
sound and crepitous, and has no appearance whatever of that pro- 
ive induration found in the peripneumatic affection. The sub- 
stance of the lung is, indeed, often very pole round the lueniopty- 
sical induration; sometimes, however, it is rose-coloured, or even 
red, as if tinged with fresh blood ; but, even in this case, the circum- 
scription of the indurated part is equally distinct. The indurated 

portion is of a very dark red, exactly like that of a clot of venous 
blood. When cut into, the surface of the incisions is granulated, 
as in a hepattaed lung ; but in their other characters, these two kinds 
^\ pulmonic induration are entirely different. In the second degree 
oi hepatization, along with the rod colour of the inflamed pulmonary 

10) \v>- e;ui perceive distinctly the dark pulmonary spots, the hlood- 
jid the line cellular intersections; all of which together give 
to this morbid state the aspect of certain kinds of granite, as has been 
35 



410 HEMOPTYSIS. 

already observed. In the induration of haemoptysis, on the contrary, 
the diseased part appears quite homogeneous, being altogether black, 
or of a very deep brown, and disclosing nothing of the natural tex- 
ture of the part, except the bronchial tubes and the larger blood-ves- 
sels. The latter have even lost their natural colour, and are stained 
with blood. The veins of the affected part, and also those adjoining, 
are sometimes filled with a firmly coagulated and half-dry blood. 
On scraping the incised surfaces of these parts, we can detach a small 
portion of very dark, half-congealed blood, but in a much less propor- 
tion than we can press out the bloody serum from a hepatized lung. 
The granulations on the incised surfaces have also appeared to me 
larger than in cases of hepatization. Sometimes the centre of those 
indurated masses is soft, and filled with a clot of pure blood. 

" This morbid affection is evidently produced by an effusion of 
blood into the parenchyma of the lungs, in other words, into the 
cells. From its exact resemblance to the effusion that takes place 
in the brain in apoplexy, I have thought the name pulmonary apo- 
plexy very applicable to it. Some examples have occurred of sud- 
den death from haemoptysis, wherein the substance of the lungs was 
found lacerated, and containing clots of blood. Corvisart mentions 
one extraordinary case of this kind, in which the extravasation had 
lacerated the lung, and filled the cavity of the pleura. The haemo- 
ptysical engorgement above described, is only a lesser degree of the 
same affection, in which the effused blood (still in some degree under 
the influence of vital action), coagulates, in the air-cells, in such a 
manner as to form an intimate union with the pulmonary tissue, 
very different from what would be produced by the mere physical 
coagulation of the blood. We sometimes find two or three similar 
indurations in the same lung, and frequently both lungs are affected 
at the same time. They take place most commonly in the central 
parts of the lower lobe, or towards the middle and posterior part of 
the lungs: it is consequently on the back and inferior part of the 
chest that we ought to search for them with the stethoscope. 

" This affection is as easily distinguishable from the congestions 
that take place after death, as from the alterations produced by the 
peripnenmony. The sanguineous congestions of the dead body con- 
sist of an accumulation of blood intermixed with serum, often spu- 
mous, which flows plentifully on an incision of the part, and tinges 
the lungs of a livid or vinous colour. Being the mere consequence 
of gravitation, the engorgement is found most considerable in the 
most depending parts of the lungs, and gradually lessens towards 
the superior parts. Where most engorged, the part still retains some 
crepitation, and the incised surfaces are never granulated, even when 
the congestion is so great as to destroy the spongy character of the 
lung. By washing, we can, in every case, remove all the red, and 
restore the lung to that sort of fiaccidity which it possesses when 
compressed by a pleuritic effusion. The engorgement of haemopty- 
sis, on the contrary, is accurately circumscribed, very dense dark-red 
or brown, granulated, and almost dry when incised, and grows pale 
by washing, but without losing any part of its consistence. What- 
ever may be the severity of this disease, resolution seems to take 






HEMOPTYSIS. 411 

place with considerable facility, since we find a great many cases of 
recovery after severe haemoptysis. I have not had many opportu- 
nities of tracing the progress of this resolution by morbid dissection; 
but in the small number of cases which I have met with, it has 
appeared that the indurated parts passed successively from dark red 
to brown and pale red; and that, in proportion as the colour faded, 
the parts lost their granular texture and their density. I do not 
think that this obstruction is followed, at least constantly, by oedema, 
as is the case with the obstruction of peripneumony. When the 
resolution is complete, it leaves no trace of disease in the pulmonary 
substance, since I have never been able to find any vestige of the 
induration in subjects who have been affected with severe haemor- 
rhage at a period of some years — or only some months — anterior to 
their death."* 

Treatment of the second variety. — The treatment depends very 
much upon the condition of the lungs, the age and constitution of 
the patient, and upon the quantity of the blood already lost. The 
plan of bleeding, in every case of bloody discharge from the lungs, 
is very bad; because it is bleeding for a name, without pathological 
considerations. In this variety, however, copious venesection is to 
be employed early, and carried to such an extent as will render a 
repetition generally unnecessary. It is employed to reduce plethora, 
and to moderate the action of the heart and arteries — to change the 
determination of blood quickly — and, on some occasions, it is to be 
carried the length of inducing syncope. It requires considerable ex- 
perience to act properly on such occasions; for sometimes, in very 
stout plethoric people, we ought to take away a large quantity of 
blood, say to the extent of three or four pounds; and to prevent syn- 
cope from taking place before we obtain sufficient quantity, the ope- 
ration should be performed when the patient is in the recumbent 
posture. When we wish to induce syncope, or to alter the tide of the 
circulation as quickly as possible, and at a small expense of blood, a 
<»ri(ice should be made, or a vein in each arm opened at the 
same time, and the patienl kept in the erect posture. It is curious to 
observe, that Laennec recommends bleeding in large quantities, even 
to syncope, in this complaint, and pursues quite an opposite course 
in pneumonia. With regard to bleeding in tins disease, he uses the 
following language: — "Hut the extreme danger which attends the 
bflemoptysical induration, and possibility of its resolution, ought to 
make us boldly us.; copious venesection from the onset of the dis- 
Onc blood-letting of twenty or twenty-four ounces on the first 
or second day, will have more effect in checking the lurniorrhage, 
than several pounds taken away in the course of a fortnight. It is 
even beneficial, in general, to induce partial syncope by means of 
the lirst bleeding. In eases of this kind, the tear of exhausting the 
patient*i strength is without grounds, since we know that the most 
copious venesection falls short of ihe loss of blood sustained from 
pulmonary hemorrhage in young and robust subjects, even in the 
Course ot a few minutes; while the debilitating cllect of the h;emor- 

• Forbes'* Translation, p. 1*1. 



412 HEMOPTYSIS. 

rhage is infinitely greater than the loss of blood produced by the 
lancet." 

After great losses of blood, whether by the lancet or otherwise, 
the state of the circulation must be carefully watched ; — much more 
carefully, the larger the quantity lost ; and we must take care not 
to lose the vantage-ground, by subsequent imprudence on the part 
of the practitioner, or on that of the patient. For this purpose, 
perfect rest, quietness, and complete silence, are to be enjoined ; cool 
air is to be freely admitted; but I have seen great injury done by 
keeping the temperature of the body too low, for too long a period, 
which promotes the tendency to internal congestions. One bleeding 
ought, in general, to suffice, provided it be carried far enough. The 
circulation is afterwards to be controlled by nauseating doses of 
antimony, the rigid employment of the antiphlogistic regimen, and 
the exhibition of laxatives. But if the patient have lost too much 
blood before we are called, or should the haemorrhage continue after 
copious bleeding, then we must trust, to the effects of the acetate of 
lead, in considerable doses, which I have seen useful in suppressing 
haemorrhages which were afferwards proved by dissection to have 
proceeded even from a ruptured blood-vessel in the lungs. 

Drawing blood by leeches is scarcely ever admissible, unless to 
mitigate some local pain in the chest, which, however, is better 
effected by a blister. 

If the patient be thirsty, acidulated drinks may be allowed. 

Some have recommended ice to be piled upon the chest in such 
cases, which surely must be a dangerous practice. 

[Yet the temporary application of ice to sensitive parts, especially 
to the genitals, will check haemoptysis when all other means have 
failed. This plan, in plethoric persons, is scarcely admissible until 
active general remedies have been premised; but it is adapted to 
delicate constitutions, and especially where the bleeding has fre- 
quently recurred.] 

Haemoptysis sometimes takes place in consequence of aneurism of 
the aorta, of which I have seen three cases, all of which proved fatal; 
the blood found its way into the bronchial tubes by absorption and 
ulceration of that part of the lung which came in contact with the 
aneurismal sac, and which, in fact, formed at least a part of the sac 
itself. In two of these instances, the parts were strengthened, and 
life preserved for a considerable time, by the usual deposition of 
coagulated blood, found in aneurisms, till at last the fatal haemoptysis 
occurred, and the patients died in a few minutes. In the third case, 
a deposition of coagulable lymph had, perhaps, for a long time pre- 
vented the eruption of blood, which, at last, however, took place, but 
was soon suppressed by moderating the force of the circulation by 
bleeding; but it returned repeatedly, and at last carried off the patient 
almost in a moment. On dissection, a considerable portion of the 
lung was found injured, but the loss was partly repaired by a thick 
and dense layer of coagulable lymph, the upper part of which was 
found detached, at which point the blood had passed into the bron- 
chial tubes. 

I have seen haemoptysis take place, probably from hypertrophy of 



HEMOPTYSIS. 413 

the heart ; and I once witnessed a dissection, where complete apo- 
plexy of the whole of one lung had taken place, the other having 
been, for years, as far as we could judge from the history of the case, 
in the most perfect state of hepatization from chronic inflammation. 
The patient complained occasionally of attacks of asthma, and ex- 
perienced much embarrassment in going up hill or ascending a stair. 
He died in a moment, after discharging a mouthful or two of blood. 
A drawing, showing the external appearance of both lungs, and their 
internal structure, is in my museum. 



35* 



CHAPTER VI. 
PHTHISIS PULiWONALIS. 



Phenomena. — If a person be frequently apt to take cold from 
slight causes — if his lungs be easily irritated at all times, so as to pro- 
duce coughing— is of spare habit and ill-formed thorax — and if many 
of his predecessors have died of phthisis, considerable apprehensions 
ought to be entertained for his safety. Care and good management 
may, however, be useful in meliorating symptoms and warding ofF 
danger. 

If an individual have laboured under bronchitis, peripneumony, 
or pleurisy beyond the ordinary period, in spite of the usual means 
employed early, tubercles may be suspected to exist already, or their 
formation may be dreaded; and if any predisposition have been 
shown, the result of the case will be still more doubtful. If he con- 
tinue coughing, losing flesh, and looking pale, the pulse becoming 
more and more frequent, with increasing dyspnoea, and expectoration 
of a copious mucus, almost colourless and semi-transparent, the 
chances are much against him ; particularly, if the sound elicited by 
percussion be dull— if the respiratory murmur be not heard at all, or 
only indistinctly, the patient may be almost declared to have confirm- 
ed phthisis. If the skin become discoloured, with diminution of flesh 
— if shooting pains be felt in the breast and back, between the clavicle 
and scapula — if there be frequent cold shivering — if the nails are 
turned in, the pulse still inrceasing, with viscid perspirations — if the 
expectoration be cream-coloured, looking granular, adhering firmly 
to the vessel, or if it should look bloody, or like milk and water, with 
a cheesy-looking matter floating on it, a still worse opinion of the 
case may be formed. If, however, he be troubled with haemoptysis 
now and then — if the expectoration continue for some time — if his 
hair look mangy, with increasing dyspnoea and weakness— and if 
the sound in the upper part of the chest, instead of being dull as be- 
fore, become clear — if a gurgling noise be heard on applying the 
ear to the chest, or if, when the person speaks, the sound of the voice 
appear very clear through the stethoscope — the person may, without 
any doubt, be pronounced to be affected with pulmonary consumpr 
tion. 

Sometimes the first and most important symptom throughout the 
affection is haemoptysis. I have seen some cases where diarrhoea 
came on with the cough, and continued throughout the rest of the 



[PHTHISIS PULMONALIS.] 415 

patient's life ; in general, however, it exists for the last six weeks or 
two months only. I have rarely seen a person live beyond twelve 
weeks after the first appearance of diarrhoea, accompanied by griping 
pains in the bowels. Sometimes the bowel-complaint alternates 
with violent perspirations, but occasionally they coexist. Sometimes 
an individual has no pain from the beginning; at others, the pain is 
occasionally very acute, not only in the bowels, but in the thorax. 
Occasionally there is little cough, and little or no expectoration, the 
mildness of the symptoms causing great uncertainty in forming a 
diagnosis; and truth compels me to acknowledge, that auscultation 
and percussion cannot always remove the mystery which hangs 
over the case ; but as soon as the tubercles soften, and become dis- 
charged through openings into the bronchial tubes, then the stetho- 
scope will commonly be of use. 

According to Louis, who has written the best treatise upon this 
subject which has yet appeared, haemoptysis occurred in two-thirds 
of his phthisical cases, and on many occasions it took place before 
the expectoration and the cough. He has been led to conclude, that 
a profuse haemoptysis renders the existence of tubercles in the lungs 
very probable. This symptom showed itself more frequently in 
women than men, in the proportion of three to two. 

It is frequently difficult to say whether the pain in the chest be 
owing to an affection of the muscles, or the formation of tubercles 
in the lungs ; in the latter stages there can be no doubt that it is pro- 
duced by pleuritic inflammation in the course of the formation of 
adhesions, which are almost constantly found when a cavern is 
situated near the surface of the lung. 

Diarrhoea showed itself in all Louis's cases; and when I state the 
appearances on dissection, it will be seen that this symptom is pro- 
duced by irritation and ulceration of the bowels. Sometimes the 
appetite is not at all impaired, even when diarrhoea prevails; at 
other times the appetite is bad and fastidious, with frequent attacks 
of nausea, and sometimes vomiting. Occasionally there is pain in 
the right hypochondriac region. The tongue presents various appear- 
ances ; sometimes, in the first part of the disease, it is perfectly clean 
and moid ; at others loaded, exceedingly rough and cracked, with 
considerable redness at the edges; and in the last stage, when there 
are extensive ulcerations in the bowels, it has the same appearance 
as that already described in dysentery, viz., as if skinned, perfectly 
raw, red and glased. The lining membrane of the month and 
tongue is sometimes covered with aphthous ulceration, which aggra- 
vates the patient's, suffering very considerably* Occasionally the 
epiglottis, pharynx, and oesophagus are similarly affected, producing 
great thirst, and difficulty in swallowing fluids as weil as solids. 

[ Slethoseo/ne sign*.— When tubercles are of the miliary form, and 
equally distributed through the lungs, they may exist by thousands 
without conveying any unequivocal Signs of their presence. We 
may saspeot them from collateral circumstances, we may feel confi- 
dent tint they do exist,but,judgtng from auscultation alone, we might 
R in uncertainty. If, however, the tubercular secretion is par- 
tial, or is more developed in ony part than in another, the signs on 



416 [PHTHISIS PULMONALIS.] 

percussion and auscultation assume a determinate character, and are 
therefore invaluable. The resonance on percussion, for example, is 
diminished in clearness as well as duration, with sometimes a dull or 
flat sound which has been compared to that derived from striking 
apiece of wood. If the clavicle "when struck about its middle, 
yields a dull sound, or duller on one side than on the other, it is ex- 
ceedingly probable that the lung is in that part affected with phthisi- 
cal degeneration. Great care must be taken to strike both clavicles 
at the same point; for the natural resonance is always less according 
to the distance of the point struck from the sternum. When the 
disease is extensive, the dulness of percussionary resonance extends 
to the infra-clavian region ; and there is sometimes such an accumu- 
lation of tubercles about the root of the lungs, as to cause a dull 
sound on percussion between the scapulae."* 

Under these circumstances the respiratory murmur, as heard by the 
stethoscope, becomes weak, and in some points almost suppressed, 
while in the adjacent parts it may be preternaturally loud. The ex- 
piratory murmur is particularly marked both in duration and in- 
tensity, together with some degree of the flowing sound and of bron- 
cophony.t But in forming our conclusions from these phenomena 
we are judiciously reminded by Dr. Williams to observe whether 
there is any obvious difference between the two sides of the chest. 

In the stage of induration of the pulmonary tissue, a new means 
of diagnosis has been pointed out by M. Louis, and is thus described 
by Dr. Gerhard. " It is the greater loudness of the sound of the 
heart, opposite to the tubercles, which serves as a better conducting 
medium than the cellular tissue of the lungs. If the tubercles are 
most numerous in the right lung, the pulsations are heard more dis- 
tinctly there than at the corresponding part of the left ; and then we 
infer, with great certainty, that the lungs are indurated. Should the 
tubercles be much more numerous in the left lung, then a careful ex- 
amination is necessary to ascertain the limits of the sound of the 
heart, and the manner in which it ceases. If the left lung be much 
diseased, the sound is nearly as loud at its apex as at the precordial 
region. "J 

In a later stage of phthisis, or that in which the tubercles become 
enlarged and softened, the dulness on percussion becomes strongly 
and unequivocally marked, and the heart's sounds are now trans- 
mitted with unnatural clearness. The stethoscopic signs are nume- 
rous, blended and even confused; as the blowing, crepitant and crack- 
ling sounds, decided bronchophony, and short or checked respiration. 
To these appearances we may add an obvious depression or flatten- 
ing of the chest beneath the clavicle, and impeded motion of the ribs 
as manifest to the eye. The preceding symptoms, considered in 
reference to those febrile, catarrhal and other characteristic evidences 
which are almost always more or less strongly marked, will enable 

[* Williams.— Physical Signs of Diseases of the Lungs and Pleura, p. 166.] 

[+ Dr. Watson has aptly defined bronchophony to be a "sound like that of a person 

talking in a tube, and whose words, for that reason, are muffled and indistinct." 

— Practice of Physic, p. 472.] 
[t Diagnosis of Diseases of the Chest, p. 108.] 






[PHTHISIS PULMONALIS.] 417 

the physician to announce a positive diagnosis long before cavities 
are formed by the elimination of tubercular matter. 

When the latter condition, however, does take place, the physical 
signs assume at once a new and decided character, and seldom leave 
occasion for doubt or difficulty in the diagnosis. If the cavity or 
abscess is large, the resonance, on percussion, is as sonorous as in the 
healthy lung, sometimes more so ; but it is uniformly hollow, and if 
the patient have his mouth open, the sound is not unlike that which 
is yielded by a cracked earthen vessel. In other instances, in which 
there is only a small cavity, or, indeed, many small abscesses, the 
dull sound of the indurated stage is still present, and even in increased 
degree from the yet further destruction of the vesicular tissue. 

Auscultation, in this stage of phthisis, yields the following sounds : 
Cavernous and amphoric respiration, mingled and alternating with 
various rhonchi ; gurgling orbubbling; pectoriloquy; metallic tinkling 
or echo; certain clicking sounds, and various modifications of the 
cough itself.* It is in the next place requisite to inquire briefly into 
the individual peculiarity of these morbid sounds. 

1. The cavernous is a modification of the blowing respiration, in 
which the ear receives the impression of air passing into and out of 
an excavation of moderate size; these sounds, or murmurs, are hol- 
low, blowing and strongly metallic. 

2. The amphoric respiration is also of the blowing kind, and 
differs only from the simple cavernous variety in yielding the sound 
as if it were passing into a large, empty cavity, such, for example, as 
a pitcher. 

3. The gargouillement, or gurgling rhonchus, is derived from the 
presence of pus or other fluid in the cavity of an abscess which com- 
municates with the bronchia, so that the air passes in and out with 
a sound like that produced in water when we blow into it through 
a pipe-stem or other tube. "It may be considered as an exaggera- 
tion of the mucous rhonchus, and it so nearly resembles that produced 
in t he trachea and large bronchial ramifications, that the symptom 
must be considered doubtful when heard only near the sternum, or 
in the axilla, in l/tt> upper part of the interscapular regions, as it 
may here l»- produced by the air-vessels." A little experience, how- 
ever, enables the practitioner to distinguish between these two morbid 
conditions, and the diagnosis is really of great importance. When 
the cavity becomes emptied of its fluids, the cavernous rhonchus 
is changed for cavernous respiration, of which we have already 
spoken. 

i. Pectoriloquy. — This phenomenon is marked by a peculiar reso- 
nance of the voice of the patient, which appears to pass through the 
itethoecops to the eai of tin' observer. In its most perfect state the 
sound is loud, distinct and somewhat metallic. These symptoms 
i <<Ttain indication of cavities in the lungs, to which the sound 
oi tii.' voice is propagated through the bronchi; ami thus to the; stc- 
ope. Hence, as Dr. Williams observes, the most unequivocal 
►riloqay is produced from cavities of moderate size situated 

.»Walhhe.— Physical Diagnosis, 4c, p. 188.] 



418 [PHTHISIS PULMONALIS.] 

near the surface of the kings, and fully communicating with a large 
bronchial tube. 

5. Metallic tinkling.— When there is a cavity of some size 
communicating with the bronchia by a small opening, there is often 
a sharp ringing sound, like that produced by striking with a pin 
against the sides of a glass or metallic vessel ; this is the metallic 
tinkling; and when the sound is prolonged and vibrating, the name 
of metallic echo has been given to it. 

6. The Latin word rhonchus, and the French rale, and the English 
rattle, are synonymous, and apply to a class of unnatural sounds, 
produced by partial obstructions to the passage of the air through 
the bronchial tubes. Every one who is the least accustomed to 
auscultation, is familiar with various modifications of these rhonchi, 
which, besides being classed as dry and humid, are called, according 
to the attendant phenomena — ivhislling, clicking, snoring, rub- 
bing, cooing, crepitant, crackling, mucous, cavernous, 4*c. fyc. 

We have not space, on the present occasion, to analyze these 
varied phenomena, or to enter into further explanations; but we feel 
confident that these few elementary remarks will enable the young 
practitioner to pursue his observations with advantage, and espe- 
cially if he avails himself of the instructive explanations contained 
in any of the treatises on auscultation, to which we have referred. 

Once for all, we call attention to the importance of examining 
pulmonary invalids in relation to deformities of the chest, which, in 
modern pathological language, are called hetero-morphisms. They 
almost invariably attend or follow pleuritis, pneumonia, phthisis, 
emphysema, &c. &c, and often so manifestly as to strike the eye of 
the observer the moment the chest is exposed to view. In other 
instances, they are best detected by standing behind the patient and 
looking down from the clavicles, when the scapulae or ribs of one^ 
side or the other will be found projecting, or retracted, elevated or 
depressed, in a manner that at once conveys an important means of 
diagnosis. These malformations are also discovered, and their pro- 
gress noticed by measuring with tapes or other contrivances; but 
this, although satisfactory for comparison, is seldom important in 
practice.] 

Appearances on dissection. — Bayle divided phthisis into nearly 
as many species as there have been diseased appearances found in 
the lungs; but Laennec and Louis, on the other hand, think there 
is only one species of phthisis, the tubercular. The latter author 
states, that he has not examined the body of one subject, without 
finding as the principal lesion, tubercles or tubercular excavations, 
or the demi-transparent gray granulations; he joins Laennec, there- 
fore, in stating, that the existence of tubercles in the lungs is the 
cause, and constitutes the proper character of phthisis. 

Before describing the various morbid appearances found in sub- 
jects who have died of phthisis, I shall seize the opportunity of stating 
some particulars respecting those accidental formations which are 
called tubercular. They are bodies of a yellowish, dull, white colour, 
variable in consistence, which subsequently soften. When situated 
in the lungs, they are sometimes expectorated by the bronchi, giving 



PHTHISIS PULMONALIS. 4,9 

rise to excavations more or less extensive. They are always more 
numerous, larger, and more advanced in their development, towards 
the superior part of the lungs, than in the lower lobes. Out of one 
hundred and twenty-three dissections, Louis mentions having seen 
two exceptions only to this rule; for some years past I have seen 
one exception only, and in it the superior lobe was quite healthy. 
Thenard's analysis of tuberculous matter gives 98 parts of animal 
matter in the 100; the remaining two parts consist of phosphate and 
carbonate of lime, muriate of soda and oxide of iron. According to 
Laennec, tuberculous matter may be developed in the lungs under 
two forms — insulated bodies, and interstitial injection or infiltration. 
He divides the insulated bodies into four kinds— miliary, crude, 
granular and encysted ; the second has three varieties — the irregular, 
the gray, and the yellow. Under any of these forms, the matter 
presents, in the early stage, a gray semi-transparent substance, 
which gradually becomes yellow, opaque and dense; it afterwards 
softens, and gradually becomes converted into a fluid, like thick- 
cream or pus, which, being expelled through the bronchi, leaves 
cavities in the lungs which were formerly termed ulcers. 

Miliary and crude tubercles. — This variety of tubercle is the 
most common. The size varies from a millet to a hemp seed, very 
irregular in shape, and as firm as cartilage. At first they are dis- 
tinct, and afterwards become grouped together, and very often rim 
into one another, so as to form one mass. A small yellowish opaque 
point appears near the centre of each tubercle, which gradually en- 
larges, till it involves the whole mass; it cuts like cheese, and con- 
stitutes the crude tubercle. Sometimes the miliary tubercles do not 
coalesce, but continue to the last distinct, and sometimes acquire con- 
siderable size. Sometimes distinct masses are seen, which are fre- 
quently the product of many tubercles united together. 

Granular tubercles. — These are spherical shaped bodies, inter- 
spersed, perhaps, through a whole lung; they were first described 
by Bayle, and were considered by him to be distinct from tubercles. 
Bill Laennec and Louis assert that they are nothing more than the 
ordinary tubercle in its first stage; the former distinctly states, that 
the only difference between these granulations and the yellow tuber- 
cles, is that between green and ripe fruit ; " besides, (says he, at page 
875,) the miliary granulations are never met with, except in lungs 
in winch there exist at the same time other tubercles of a larger size, 
and sufficiently advanced to render their character no longer matter 
of question.' 1 .My observations oblige me to dissent from this state- 
ment. Within the last six years, 1 have seen a considerable number 
of instances, in winch granular tubercles pervaded the whole of both 
lungs; they were all nearly about the same size; the surrounding 
pulmonary tissue- was of a red colour. Several drawings, showing 
these appearances, are in my portfolio. In these cases, there was 
httle cough, and very slight expectoration \ and in one adult, the 
lungs weighed nine pounds and three quarters. Three cases were 

children; in two of winch, tubercles were found on the arachnoid 

coat of the braiu also; and in one, the membranes, on one of the 

hemispheres, were ulcerated in a great many points, This kind of 



420 [PHTHISIS PULMONALIS.] 

tubercular formation in the lungs has long engaged my attention, and 
I feel convinced they are the air-cells distended and enlarged by a 
diseased deposition, probably the consequence of inflammation of 
their inner membrane. A similar appearance may be produced by 
pouring a little quicksilver into the air-passages of a rabbit, if it be 
allowed to live for some days after the experiment. At one time, I 
felt disposed to believe, that bronchitis was the cause of almost all 
tubercular formations in the lungs ; which opinion appeared to be so 
far confirmed by a well-known fact, that the majority of individuals 
who died of phthisis, attribute their illness to what they call a ne- 
glected cold ; but I have been induced to abandon this opinion. 

Encysted tubercles are rare. I have seen cases where one, two, 
or three encysted tubercles were found in the lungs, about the size 
of a filbert, inclosed in a cyst. Two of the cases died of hooping- 
cough, and another of the disease called tabes mesenterica. In all 
these cases, the surrounding substance seemed somewhat firmer and 
redder in colour than usual, but in other respects, there was no dis- 
ease in the substance of the lungs. Laennec says they are rare, and 
Louis declares he has only seen one instance of this formation. On 
making a section of the tuberculous mass, it appears of a whitish 
colour, semi-transparent, and of a texture like hard cheese; but for a 
more minute account, I must refer to the works of the above authors. 

With respect to the tuberculous infiltration, I have to observe, 
that it is commonly of a grayish-white colour, sometimes with a rose 
tint, and is found either surrounding tuberculous excavations ; or 
existing in large masses, occupying the whole lobe of a lung, having 
no connection with the miliary tubercle; indeed, I have a prepara- 
tion in which every part but the superior lobe is infiltrated with this 
matter, and I have an idea that this may be one of the occasional 
ultimate terminations of the granular tubercle. This opinion is 
somewhat supported by Laennec's description of the gray tubercu- 
lous infiltration. 

According to Laennec, tubercles first show themselves in the sum- 
mit of the upper lobe, more particularly on the right side; while 
Louis states, that they are more frequently met with in the left lung. 
My own experience corroborates Laennec's statement. 

An important question is still undecided, and perhaps will remain 
so, as to the cause of this singular formation. Some insist that 
tubercles are the product of inflammation of a peculiar kind ; while 
others, with as much confidence, allege that they have nothing what- 
ever to do with inflammation, except inasmuch as they sometimes 
excite it by mechanical irritation. Many advocate the fluid origin 
of tubercles, and Dr. Baron maintains that they are primitively hy- 
datids ; and although he has supported his doctrines with much 
learning and ingenuity, yet I feel persuaded he has not convinced a 
single pathologist. 

[Much observation and reflection devoted to this subject, have led 
me to adopt the following propositions; but for the full elucidation of 
several of these, the profession is mainly indebted to the celebrated 
Andral : 

1. Tubercular matter is a secretion from the blood-vessels. 



[PHTHISIS PULMONALIS.] 421 

2. This secretion is a morbid condition of the albuminous halitus 
proper to the cellular tissue forming the parenchyma of organs. 

3. Inflammation is not necessary to its development, but may be 
either a cause or consequence. 

4. The cellular tissue which envelops and intersects tubercles, 
sooner or later takes on inflammation, and secretes pus; by which 
process the tubercular matter is eliminated, and an abscess is formed. 

5. The morbid state immediately antecedent to the tubercular se- 
cretion, and which may be considered its exciting cause, is a san- 
guineous congestion analogous to that which precedes every secre- 
tory process. 

Physiology teaches us that in the healthy living body there is a 
constant secretion, from the blood, of an albuminous halitus, which 
is deposited in every part of the system, and in no structure so abun- 
dantly as the cellular tissue. Whatever deranges this interstitial 
secretion tends to the production of preternatural substances: hence 
any irritation may act as an exciting cause; not that it necessarily 
increases the activity of the secretory process (which in health is very 
prolific) but because it perverts this important function. 

Such appears to have been the opinion of the indefatigable 
Baumes, who, in his work read before the Medical Society of Paris, 
in 1783, holds the following language; "An organ that has become en- 
feebled, secretes its peculiar fluid in an imperfect manner; these fluids 
no longer possess the degree of vitality necessary to stimulate and 
support the solids ; they become from day to day more unnatural, until 
at length they cease to have any analogy with healthy structure."* 

Analysis has proved tubercular matter to consist almost entirely of 
albumen, showing its affinity, in this respect, to the healthy interstitial 
secretion, from which it mainly differs in certain physical characters. 

Th" reason why the tubercular secretion is so much more common 
and abundant in the lungs than in other structures, is that the former 
are composed of a most delicate series of tissues, which are pre-emi- 
nently exposed to the many vicissitudes arising from atmospheric 
Changes, inordinate physical exertions and direct mechanical irritation. 

Tubercular disease is by many considered to be invariably a pro- 
duet ci| inflammation :t but although the latter often accompanies it, 
and always in its second stage, it appears to me by no means essen- 
tial to its secretion, any more than to the deposit of osseous particles 
in the mats of an artery, or in the substance of a cartilage. 

Tnberclefl are often found in great numbers in the lungs after death, 
without their having been even suspected during life ; and if these 
tnberclefl hive not passed into the crude state, the parenchyma 
ground them is often found perfectly healthy, presenting, in fact, no 
trace of pneumonia. Could the pulmonary tissues maintain this in- 
tegrity if each tubercle was a centre of inflammatory action? It ap- 
pear* to me that inflammation is much oftener a consequence than a 
cause of tubercles; the latter forming independently of it, and sub- 

l«De i.i PhiMM.-, tome i. p. 186.] 

ft" I have never leen loberclei of ill'' long! without a preceding Inflammation, 
which an (band in children ■<! btrtb, '!<> nm appear to ni<- to be independ- 
ent of ilns phenomenon." — Brtnuais. Kt.-mii.-ii dee Docu inea Bdediceles.] 
36 



422 PHTHISIS PULMONALIS. 

sequently inducing phlogosis like any other extraneous bodies. Thus 
it is that tubercles induce pneumonia ; while, on the other hand, 
pneumonia is a cause of tubercles; for I conceive it to be inconsist- 
ent with analogy as well as with fact, to restrict this secretory pro- 
cess to an inflammatory state of the vessels, and vice versd. This 
exclusive doctrine (to which I was at one time strongly biased), has 
given rise, among pathologists, to those conflicting views, which can 
only be reconciled by a concession like that here admitted, and which 
is founded on the known phenomena of diseased action. 

The theory of the lymphatic origin of tubercles, which is now so 
generally received, is at least as old as Sylvius, (1761,) who supposed 
the lungs to contain an infinite number of minute conglobate glands, 
analogous to those of the mesentery. This opinion has been ampli- 
fied with great ingenuity byM. Broussais, who attributes tubercular 
matter to an inflammation of the lymphatic glands and vessels con- 
sequent to inflammation of the sanguiferous capillaries; in fact, a 
double inflammation, beginning in one set of vessels and thence 
propagated to another. 

Without entering into a discussion of this question, I will merely 
observe, that if tubercles originate solely in lymphatic glands and 
vessels, ought we not more frequently to meet with them where 
these structures are most abundantly distributed, as in the axilla and 
groin, the mesentery, neck, &c? Yet it often happens that in per- 
sons who have died of phthisis, we see the bronchial, axillary, and 
inguinal glands greatly tumefied and diseased, without being at all 
tuberculous; while, on the other hand, we find the same hypertrophy 
and disease of the bronchial glands in those pulmonary affections in 
which tubercles have had no part. 

This hypothesis presupposes the existence of innumerable minute 
glands in the lungs; but anatomy, even aided by the microscope, has 
never detected them: moreover, a true tubercle has not the ana- 
tomical characters of a gland, for it is closely attached to the sur- 
rounding parenchyma ; whereas all glands, especially when enlarged 
by disease, possess their proper ca'psules, which enable them to be 
dissected out with facility.] 

The body of a person who has fallen a victim to this very dread- 
ful disease, is found greatly emaciated, sometimes to the last degree, 
and the chest looks contracted on itself, which may, however, be a 
deception produced by the general emaciation. Laennec thinks the 
contraction of the chest is real, and is to be attributed to two causes. 
1st. To the existence of pleurisies, to which phthisical patients are ex- 
tremely liable. 2dly. To the attempts made by nature to cure phthisis. 
On opening the thorax, the heart is sometimes observed to be small; 
Laennec says it is almost always remarkably so. The lungs are 
sometimes found adhering throughout their whole extent to the ribs, 
and the left lung is frequently attached to the pericardium, which is 
occasionally distended with serum. Sometimes one side of the tho- 
rax contains a puriform matter, with a considerable quantity of air, 
the result of a vomica bursting into the cavity, leaving a communi- 
cation open with the bronchial tubes; when this is discovered, the 
person is said to be aifected with pneumothorax, which may be 



PHTHISIS PULMONALIS. 433 

ascertained by the splashing noise which is heard, when the patient's 
body is shaken by the shoulders; the stethoscope communicates a 
peculiar sound, called the metallic tinkling. The powers of the 
constitution, however, employed to prevent this accident, are gene- 
rally successful, by effusion of lymph, and the agglutination of parts. 
These adhesions are mostly found to affect the superior lobes, and 
sometimes are so dense, that it is impossible to separate them with 
the fingers, without tearing the lung itself. 

On removing the lungs from the body, they are found to be much 
heavier than natural ; one case I have already mentioned, in which 
they weighed nine pounds and three quarters. Notwithstanding the 
assertion of Laennec to the contrary, I have several times seen the 
marks of the ribs left upon the posterior and lateral parts of the 
lungs, when they were very heavy.* It was seen in two cases in 
which the lungs were extremely dense and large, the effect of long- 
protracted chronic peripneumony. 

On making a longitudinal section of the lungs, which will usually 
be found " to cry under the knife," we sometimes find one excava- 
tion only, which may be full, none of the contents having yet found 
their way into the bronchial tubes; and when solitary, it is almost 
always in the superior lobe. In general, however, many cavities 
are found, containing more or less softened tuberculous matter, and 
the most striking difference will be observed in the progress of the 
tubercles in different situations, being commonly farthest advanced 
in the superior parts; occasionally they present the appearance of 
fresh crops. Sometimes the lung is found studded with miliary 
tubercles, affecting the pleura also, and most commonly some of the 
bronchial glands will be found enlarged and hard, sometimes mela- 
notic. I have met with this condition of the lungs only twice or 
thrice; the subjects were children. I have seen several dissections 
in which the tubercles, called granular by Bayle, were found in 
immense numbers, dispersed with great regularity throughout the 
whole substance of the lungs, with intervening spaces of a red 
colour, having the appearance of the roe of a salmon. 

tonally we find a chain of excavations extending through- 
out the whole lung, communicating with each other; the tubercles 
having become successively softened, and then discharged. In these 
exe&vationfl bands are seen stretching in every direction, like the 
fleshy columns in the ventricles of the heart, which seem to be com- 
poMd of condensed pulmonary tissue, coated over with tuberculous 
mutter, or, as it has occasionally appeared to me, coagtliable lymph; 
these bands sometimes contain blood-vessels. Bayle makes the same 
remark', which 18 questioned, however, by Laennec, who states that 
he has " never even found a vessel of am/ rmi.sci/iirnre included 
within the substance of these bands;" but I liave had several oppor- 
tunities of demonstrating it to my class. Indeed, on one occasion, a 
laru". blood-vessel in one of these bands gave way, and the child 
quickly died. Tins is the cas.; previously noticed and in which 
the Mood found its way from the cavern by a fistulous opening into 

[•II wiih a s.'lii.nry example of this kind.] 



424 PHTHISIS PULMONALIS. 

the oesophagus, as high up in the neck as to correspond to the in- 
ferior margin of the thyroid gland, and from thence passed into the 
stomach. It will be remarked that Laennec's expression is qualified, 
and I am ready to grant, that it is rare to find vessels of " any con- 
sequence" in these bands, because they must be compressed and 
diminished iu size, in proportion to the condensation of the pulmo- 
nary tissue in which they are involved. Laennec supposes that the 
tubercles, during their increase, separate the blood-vessels, and press 
them to one side, which would no doubt hold good, if there were 
only one mass; but it is not a satisfactory explanation of the situa- 
tion of the blood-vessels, when the lungs are completely studded 
with tubercles. On one occasion, I found a blood-vessel passing 
through a cavern, in one of the bands already described, which had 
become obliterated by a plug of coagulable lymph. 

The ramifications of the bronchi seem to be obliterated; they are 
frequently found to open into a cavern, but I have never seen a trace 
of (hem in the tuberculous matter. In proportion as the tubercle 
becomes softened and discharged, the walls of the excavation are 
found more or less thickly covered with something like a membrane, 
which can be scraped off with the knife. According to Laennec, 
this membrane presents, in different parts of its surface, projecting 
points. Sometimes there is an appearance of two membranes, but 
occasionally the walls of the cavity are formed by the natural tissue 
of the lung itself, condensed, red, and charged with tuberculous mat- 
ter. Sometimes the walls of the caverns appear to be lined by a 
membrane of fibrocartilaginous consistence, occasionally filling up 
a smali cavern entirely, presenting an appearance of cicatrization; in 
this way, it is supposed that phthisis is sometimes cured. 

The mucous membrane of the bronchial tubes is generally red and 
thickened ; that portion of it which lines the trachea and larynx is 
occasionally red, thickened, and pulpy, with ulcerations here and 
there. Ulcerations are sometimes seen as far down the tubes as the 
third and fourth division. Occasionally the epiglottis and larynx are 
also covered with numerous ulcerations, sometimes having the ap- 
pearance of chancres. 

The stomach occasionally presents diseased appearances, its mu- 
cous membrane being red, thickened and velvety, with dark streaks, 
as if seared with a red-hot iron. In other cases, a great portion of 
the mucous membrane is found entirely removed, generally from 
the splenic extremity, leaving the naked vessels exposed; the rest of 
the membrane being thickened, soft and reddish, with a great num- 
ber of redder spots in the neighbourhood of the parts already de- 
stroyed, as if a pen full of red ink had been spattered over the surface. 
Sometimes large red vessels are seen arborescing in the mucous 
membrane, which displays appearances here and there as if portions 
had been removed by passing the nails roughly over the surface of 
the stomach. In one case, all the coats of the stomach, except the 
peritoneal, were destroyed over a space about the size of a shilling. 
In very few cases have I observed tubercles iu the mucous mem- 
brane of the stomach ; they are frequently seen in that of the intes- 
tines, particularly in the caput caecum, ascending colon, and termina- 



PHTHISIS PULMONALIS. 425 

tion of the ileum: they are sometimes situated in the mucous coat, 
arid at others in the sub-mucous tissue. It is precisely in the situa- 
tion above described that ulcerations are most frequently found, 
occasionally involving the whole of the colon down to the sigmoid 
flexure, which is much thickened in its texure, in some cases feeling 
contracted and hard like a small rope. The state of the mucous 
membrane has been often described in this work; but I must here 
state, that I have never seen ulcerations undergoing the healing pro- 
cess in the disease now under consideration; nor the mucous surface 
in that dark, livid, fleshy, and thickened state, which it frequently 
shows in dysentery. The peritoneum is sometimes found inflamed, 
thickened, and covered with flakes of lymph, which may be traced 
to points of the intestines, at which the ulcerations have extended 
through the other tissues, till it attacked the peritoneum itself; occa- 
sionally, indeed, a small perforation is found, which has admitted 
the passage of feculent matter into the cavity of the abdomen. The 
peritoneal is frequently the seat of tubercles. They first appear, per- 
haps, in the miliary form, and afterwards become crude. I had lately 
an opportunity of seeing tubercles formed on the peritoneal surface 
of the stomach of a child, who died of chronic peritonitis, occasioned 
by ulceration of the bowels. They did not extend deeper than the 
sub-serous coat. 

The mesenteric glands are always found enlarged and altered in 
structure in phthisis when the bowels are atfected. The liver is 
sometimes found diseased, more frequently, perhaps, in women than 
in men; it is generally softened, enlarged, and of a whitish or yel- 
lowish colour, feeling greasy to the touch. This is the fatty liver; I 
have seen it so large as to fill the iliac region, the right lobe extend- 
ing down to the brim of the pelvis. The spleen is sometimes found 
tuberculated both in its substance and its capsule. The omentum is 
occasionally diseased in phthisical subjects. It is found thickened; 
fatty, like the liver, and tuberculated. 

The brain is found in various states; sometimes there is effusion 
between tin: i raohnoid and pia mater, or into the ventricles, the effect, 
in all probability, of impeded circulation. Tubercles are also ob- 
served in various situations in the brain, and in different stages, cither 
solitary in some part of the cerebral substance, or spread generally 
over the arachnoid membrane, where I have frequently seen them 
in the miliary form, as well as in a crude state. 

It has never been satisfactorily explained why ulcerations should 

be found so frequently in the mucous membrane of the bowels, in 

phthisis. It may, perhaps, be partly attributed to the obstructed State 

of the circulation, producing considerable vascular distension in its 

els, which at last become inflamed and ulcerated. There may 

t>e also something in the diseased condition of the blood itself, which 

cannot be perfectly decarbonised. I have little doubt that the mu- 
cous surface of the bowels, in the ordinary state of the system, assists 
the mugs in depriving the blood of carbon; After the lungs have 
been impeded by the tubercular state of the pulmonary substance, 
perhaps the mucous surface of the bowels becomes more active, 
thereby causing inllunmaiion and ulceration. There is no doubt 

3G* 



426 t PHTHISIS PULMONALIS.] 

that ulcerations in the intestines are sometimes owing to the irrita- 
tion of tubercles in that part, but this speaks for itself. For further 
particulars, relating to the morbid appearances found in this disease, 
the reader is referred to the work of M. Louis. 

[Causes. — Consumption is a remarkable instance of hereditary- 
disease: thus, when the parents have died of constitutional phthisis, 
the children are almost sure to suffer. This predisposition, or tuber- 
culous diathesis, is not confined to any period of life, but is most apt 
to show itself between the ages of eighteen and thirty-five years. 
Some authors have endeavoured to identify it with the scrofulous 
habit, from which, however, it appears to be entirely distinct ; scro- 
fula is most active in the juvenile state, while phthisis is a disease of 
adult age. I have twice seen the scrofulous diathesis developed in 
the spine, even to deformity, and accompanied by chronic pulmonary 
disease, without exciting a tubercle in either lung. The physical 
characteristics of scrofula and phthisis are not the same; for two- 
thirds of the consumptive patients who have come under my care 
have had dark hair, dark or sallow complexions, and dark eyes. It 
seems, indeed, extremely difficult to detect the tuberculous constitu- 
tion by any physical appearances of even general application ; and 
still more difficult to identify it with the scrofulous diathesis. 

If the predisposition to phthisis exists, various slight causes are 
sufficient to excite it into action. Thus bronchitis, pneumonia, hae- 
morrhages, the depressing passions and exhausting indulgences, bad 
diet, sedentary occupations, and a hundred other means by which 
the healthy functions of the system become perverted, may be ad- 
duced as exciting causes.] 

Treatment. — Although Laennec states that phthisis is curable, 
still such a happy event is scarcely to be expected after the disease 
is formed. The only case which I conceive to be capable of a spon- 
taneous cure, is that in which a solitary tubercle has existed, without 
any other disease of structure in the lungs. In examining the bodies 
of cholera subjects, we frequently observe puckered marks and cica- 
trices, with corresponding pulmonary indurations, sometimes to a 
considerable extent. These were evidently the situation of tubercu- 
lous degenerations, from which the individuals had quite recovered. 
Professor Lizars has, in his collection, a very valuable specimen of a 
lung entirely excavated, nothing being left but an empty sac. The 
history of the case is quite complete ; the man recovered, and was 
able to exist and support himself by manual labour, and died ulti- 
mately of typhus fever, unconnected with any pulmonary complaint. 
Much may be done in warding off the disease for many years, and 
retarding its progress after it is formed, by care in the management 
in an individual — by attending to his diet, which should be nourish- 
ing and moderate — to his clothing, which should be warm and light 
— and to his exercise, which should never be carried the length of 
producing fatigue. Constipation should be avoided, and such an 
individual should remove to a steady climate if he can afford it. 
After the disease is somewhat advanced, a great deal of expense and 
trouble may be spared by keeping the patient at home, because, at 
this period, change of climate can do no good ; on the contrary, I 



[PHTHISIS PULMONALIS.] 427 

have known it frequently to hasten the fatal termination, from fatigue 
and accidental exposure to cold during the journey.* 

[When I meet with a case of incipient phthisis, when the disease 
is confined to one lung, and is circumscribed in extent, and the pa- 
tient's general health not yet impaired, I pursue the following plan. 
I at once establish an issue of caustic potash over the diseased part, 
and keep it discharging by means of basilicon, savin, and mezereon, 
and by washing it with soap and water. The cough should be con- 
trolled through the day by demulcent and acidulated drinks; but at 
bed-time, if it continue troublesome, I direct as much anodyne as 
will secure the patient a night's rest. In this manner the cough will 
be chiefly confined to the early part of the day, when the patient is 
best able to bear it. If there be febricula, with a frequent pulse, I 
am partial to the use of digitalis, which sometimes has a most happy 
effect in reducing the wearing excitement of the blood-vessels. To 
this simple treatment I add the internal use of the preparations of 
iodine — the most powerful alterative, with the exception of mercury, 
with which we are acquainted. 

As bronchitis is often the precursor and cause of consumption, and 
especially as it may coexist for a considerable period with tubercles, 
without any positive evidence that these are present, it is well to 
regard every cough with distrust, and treat it accordingly. How 
much more is this course necessary, when we know that tubercles 
are already formed, and forming in the lungs? Of all the counter- 
acting agents for these bodies and for bronchitis, or catarrh, no one 
medicine has, in my hands, proved so efficacious as the preparations 
of iodine. Whether they be used in form of the iodides of potassa 
or iron, or of the former combined with pure iodine, the effect is 
generally prompt and salutary. We should give them freely; not 
less than two or three grains of either iodide, three or four times a 
day ; while the combination with pure iodine, for reasons I cannot 
explain, must be administered more sparingly. t 

I have resorted, also, with great advantage, to iodine inhalation. 
Sir Charles Seudaniore was, if I mistake not, the first to propose a 
systematic plan for tins purpose, or at least to combine coniura with 
iodine, and his formula 18 as follows: 

K. — Iodinii puri, 

lmii.li potassii, aa "r. vj. 

Aquae destillaie, iv. jvjj 
Alcuholis, 3J. 
Fiat mistara. 

"1 always prefer." observes the author, " to add the coniutn at 

the tune <>i mixing the iodine solution with the water ; and it should 
be a saturated tincture, prepared with the genuine dried leaves. In 
the commencement of the treatment) I advise very small proportions 
of the iodine mixture; i<»r example, only from half a drachm to a 
drachm for an inhaling of eight or ten minutes, to be repealed two 
or three tunes a, day. Of the soothing tincture, (eoniuin), I direct 

•i' maeti valuable Information on this subject, I most refer my readers V> Dr. 
J.in iworkon Pulmonary Consumption, dee. Ac., 1886. 

[1 6 I'; iriptioo, No. 36, Appendix.] 



428 [PHTHISIS PULMONALIS.] 

half a drachm, which I usually find sufficient ; but it may be in- 
creased, if the cough be very troublesome. I soon augment the 
quantity of the iodine, and progressively from 3] to 3iv; but also 
then prolonging the time of inhaling, I divide the iodine dose, put- 
ting two-thirds at first, and the rest after the expiration of seven or 
eight minutes. During the process (of inhalation) the inhaler should 
be immersed in a jug containing water of rather a higher tempera- 
ture than 120°."* 

I have thought best to give the author's directions in his own 
words, because I think it probable that some, and perhaps all the 
difficulties complained of in this formula, have arisen from some in- 
advertence in its preparation. That great care is requisite will be 
obvious to any one ; but of the efficacy of the plan, when fairly tried, 
there can be no question. 

Dr. Pearson, of London, many years ago recommended an inha- 
lation of ether, saturated with cicuta leaves; a drachm of the latter 
being kept in an ounce of the former, for about a week, at the end 
of which time, the vapour of one drachm of this tincture is to be 
inhaled thrice per diem. Having repeatedly tried this plan with 
advantage, it occurred to me to add the iodine to the cicuta and 
ether, in the following manner: 

R.— Iodinae purae, gr. iv. 

Foliorum cicutae, gr. viij. 
Etheris sulphurici, ^i. 

These ingredients are to be mixed for forty-eight hours, or a week, 
at option. 

I direct a teaspoonful of this ethereal tincture of iodine and cicuta 
to be poured into a wineglass, which is to be grasped in the warm 
hand, and the vapour to be inhaled as it rises. In ten or fifteen 
minutes the evaporation is complete ; and in this short period, the 
inhalation is completed without the inconveniences which attend 
upon the more complicated process which has been described above. 

Sometimes the ether causes cough. Every species of inhalation 
will sometimes do the same. To obviate it in the present formula, 
let the wineglass be held a few inches from the nostrils ; and if the 
vapour causes some dizziness, (which, however, can only be tempo- 
rary,) the patient may begin with half a drachm. 1 need hardly add, 
that this, and every other use of iodine is inadmissible, when active 
fever is present. 

The patient's diet should be light but nutritious ; he should use freely 
the farinaceous articles, and avoid every indigestible article of food. 
Conjoined with these means, I direct daily free exercise in the open 
air by walking, riding or driving, and by protracted journeys, when 
these can be resorted to without undue fatigue or exposure. As an 
interlude I am extremely partial to a change of climate, of which 
more will be said in the sequel. It is by a persistence in this plan 
of treatment, that I have now the satisfaction of seeing a considerable 
number of patients pursuing their daily avocations, and enjoying a 
good degree of general health, who, I am confident, never would have 

[* London Medical Gazette, 1840.] 



[PHTHISIS PULMONALIS.] 429 

survived, for three months, the old practice of close confinement, low- 
diet, antiphlogistics and mercurials. I do not pretend that in all such 
cases the tubercular disease is eradicated, or that the abscesses have 
cicatrized ; but I know that the malady may sometimes be kept at 
bay, and rendered comparatively inert, until at length it ceases to 
molest the patient. 

The obliteration of abscesses by cicatrices is a very common oc- 
currence, but most unfortunately, these cavities are seldom single or 
isolated, but, on the contrary, succeed each other at uncertain inter- 
vals, and thus keep up an exhausting drain on the constitution. 

But the existence of abscess does not prevent my pursuing the 
practice above mentioned, provided the general strength of the pa- 
tient continues in a reasonable degree unimpaired. Abscesses may 
continue for years, occasioning no pain, and little inconvenience be- 
yond debility, more or less cough, and occasional febricula. Such 
instances, however, are exceptions to a rule; for where suppura- 
tion has taken place we have little to hope for.] 

Much may also be done to retard the advancement of the disease, 
to mitigate the patient's sufferings, and to smooth his passage into 
the vale of death by avoiding every cause which can hurry the cir- 
culation and respiration, and preventing exposure ill bad or change- 
able weather. Phthisical patients suffer occasionally very severely 
from pains in the chest, produced by pleuritic inflammation, traces 
of which are almost always seen on dissection. Small bleedings, 
leeching and conira-irritation, should therefore be occasionally em- 
ployed. Profuse perspirations are to be discouraged, as is also the 
exhibition of acids, winch are so often given to prevent them.* The 
bowels are to be assiduously watched to prevent constipation, and 
the necessity of having recourse to strong purgatives, particularly 
when the disease is of long standing. When a laxative is necessary, 
it should he of the mildest description, and united, perhaps, with the 
extract of hyoscyamus. [This condition of the bowels may be, in a 
; measure, prevented by diet: thus, instead of bread made of 
wheal llnur. tin* patienl should be restricted to bran bread, conjoined 
with the free use of mam. Sound ripe fruits, and the dried fruits 
stewed, Bubserve the same purpose. ] Whenever a patient has more 
than the usual number of Stools, particularly if they are watery, 
dark-coloured and fetid, and when he begins to feel even slight un- 
easily 88 in the belly before going to stool, a i'cw leeches should be 
applied to the abdomen, followed or not, according to circumstances, 
by the application of tartar-emetic ointment to produce irritation. It 

• [I confess I cannot j"in In the author's objections io mineral adds. The nightly 
recurrence of profuse sweats i^ no debilitating, and at the same lime so distressing to 

that a physician I imeli compelled to resort to some measure that 

will ;iii"ini relief, even though ii be merely temporary. Thus l nave many times 

Ighior ten drops <>i elixir <>r vitriol, given in a little cold wain or bitter infu- 

ii bed time, produce the ba A similar r < ■ - u 1 1 may be obtained 

from ,•! lolation of alum Inspirits, whh which the limbs should !»• freely sponged. 

The I ige may be taken internally for the same purpose. I use these 

mean iliquaiive perspiration, on the same principle thai I would check a 

r in exhausting i" iii<- patienl ; and where our curative means end. 

ilHauve onrs must begin. The same remarks will apply to the diarrhoea of 

philiiMs.J 



430 [PHTHISIS PULMONALIS.] 

is wonderful, in many cases, to observe the good effects which fol- 
low the application of leeches in subduing the inflammation of the 
mucous membrane, thereby controlling the diarrhoea, and preventing 
the formation of ulcerations. Indeed, I have seen the best effects 
follow the application of leeches, even after a large extent of the 
mucous surface was ulcerated ; but superficial irritation, produced 
sometimes by a mustard plaster, sometimes by hot spirits of turpen- 
tine, or by antimonial ointment, will be often found of essential ser- 
vice, when the patient is too weak to bear bleeding. 

[The Moors of Africa, among whom consumption is common, 
have a practice of controlling diarrhoea by means of two grains and 
a half of alum, with an equal portion of sulphate of iron, given in a 
powder. Having mentioned this plan to Dr. Pitcher, of the United 
States army, he subsequently informed me, that he put it in practice 
on two soldiers who appeared to be dying with diarrhoea consequent 
to phthisis, and that both men were so greatly relieved, as to be able 
in a short time to resume their duties in the garrison. I mention 
these facts with the more satisfaction, because 1 believe patients are 
sometimes allowed to die of diarrhoea, from an impression that it is a 
mere sequel of the pulmonary affection, and therefore incurable. I 
am decidedly of opinion that we should combat the diarrhoea with 
every available means, both internal and external, to the last hour of 
life. It is now upwards of two years and a half since I had in charge 
a middle-aged man with an abscess in his left lung, which was soon 
followed by an exhausting diarrhoea; the latter was happily checked 
by strong opiate and astringent medicines, at the very time when 
the case appeared hopeless : the diarrhoea subsequently recurred 
twice, and was, in like manner, subdued, after which the patient's 
general health began to improve, aud he is at the present time able 
to take daily exercise in the open air, although he still labours under 
his pulmonary disease, and is occasionally confined with relapses of 
various kinds.] 

Peritonitis is sometimes occasioned by an extension of the ulcera- 
tion to the peritoneum ; therefore leeches and contra-irritation are 
sometimes advisable. An occasional opiate is also serviceable; and 
I have seen the best effects produced by the exhibition of one-twelfth 
of a grain of strychnine, when the bowel-complaint was very trouble- 
some. 

[Change of climate.— One of the most powerful means of eradi- 
cating or alleviating disease is change of climate. This remark is 
especially applicable to pulmonary affections. Phthisical patients 
are often improved by mere changes, even though it be from a clear 
atmosphere to one damp and unhealthy, from warm to cold, from 
cold to hot. Thus we send our consumptives to a southern climate, 
Florida or the West Indies, to escape the winter : while in the latter 
islands physicians frequently send their consumptives beyond the tro- 
pics, to England, Denmark, and the United States, to pass not only 
the summer but the winter also. It is in fact evident, that both ex- 
tremes of temperature are sometimes salutary; and that great changes, 
by acting powerfully on the constitution, are capable of breaking 



[PHTHISIS PULMONALIS.] 43 1 

those chains of morbid action which constitute the most inveterate, 
maladies to which man is subject. 

In phthisis, however, a clear, dry atmosphere, of an equable tem- 
perature, is most adapted to the majority of patients, especially if the 
exercise of travelling is precluded. Travel itself is highly beneficial, 
nor is there any means more invigorating, provided it be not carried 
to excess and consequent exhaustion. The chief reason why so few 
people are benefited by the climate of Italy is to be attributed less to 
any fault of the climate itself, than to their own imprudence. Inva- 
lids must see every thing; they persist in ascending mountains, climb- 
ing to the dome of St. Peters, the tower of Pisa, and the cathedral of 
Milan ; travelling from place to place in all kinds of weather, and 
exposing themselves to the sun, as if the mere circumstance of their 
breathing the air of Italy was a guarantee against fatigue, exposure 
and dissipation itself. 

I have considered this interesting subject at considerable length 
in another work,* and shall now merely indicate, in the briefest 
manner, certain winter resorts in the United States and West Indies, 
which have been found most salubrious under the circumstances in 
question. 

St. Augustine, in East Florida, is our principal winter resort for 
pulmonary invalids. It certainly possesses one of the most equable 
climates of the United States, yet is subject to no small vicissitudes of 
temperature; while the inadequate provision the inhabitants make 
for cold weather renders a severe winter very exposing to the sick. 
From a letter of Dr. Porcher, contained in Dr. Dunglison's admirable 
work on Hygihie, I have gleaned the following facts: 

1. The thermometer, in a solitary instance, fell 37° in 24 hours. 

"2. Changes of 20° or 25° occur frequently every winter; in some 
instances even in a few hours." These changes, however, are be- 
tween 65° and 45° or 40°. 

& The thermometer does not fall to 35° more than five or six times 
in a winter, nor does it remain so low more than a few hours. 

'I. The lowest degree to which the mercury is known to have 
fallen, is 20° of Fahrenheit; nor has it been observed to remain for 

J. 1 hours sii low lis 32°. 

"). (old weather seldom lasts beyond two or three days, and is 
generally followed by a " long succession of days with an atmosphere 
the most bland and delightful." 

It would, therefore, seem, that while St. Augustine presents an 
equable climate, it is liable to serious objections : at the same time, it 
is well known that many pulmonary invalids annually derive import- 
ant benefit from passing (he winter there. Cape Florida may yet 
prove more salubrious than St. Augustine. The Passa Christiana, 
on the Golf of Mexico, has also been much extolled as a winter re- 
treat. Texas, too, possesses a most genial climate. 

Daring the summer season, tin- Red Sulphur Springs, m Virginia, 
and the Pine region, m the viemity of IVmherton, in New Jersey, are 
' td to with great advantage by many. 

[• Illustrations of Pulmonary Consumption, U edition J 



432 PHTHISIS FULMONALIS. 

Of the West Indies, the islands of Barbadoes, Cuba and Santa 
Cruz offer the strongest inducements to the sick; but particularly the 
last named island, in which the thermometer scarcely varies 10 de- 
grees the year round. An almost constant sea breeze, a clear elastic 
atmosphere, and a profusion of fruits render this island one of the 
most delightful in the world. 

Every person, however, who visits the West India islands, must 
expect to feel the enervating influence of so warm a climate. Lan- 
guor of body and listlessness of mind are inevitable consequences, and 
indispose alike to physical and mental exertion. 

The West Indies should not be visited earlier than December nor 
later than March.] 

The duration of phthisis is very various: few survive above a 
year; indeed, the generality of patients sink in about nine or ten 
months, and I have often observed that women die quicker than 
men. One case terminated fatally in about twenty days, where there 
was no other perceptible organic lesion, except the granular tuber- 
cles which affected every part of both lungs. Louis says he has seen 
a case fatal in twenty-four days, but that the general period in acute 
phthisis is about fifty days. 

It was formerly mentioned, that Bayle divided phthisis into as 
many species as there have been diseased appearances found in the 
lungs. He has, therefore, treated of calculous concretions under this 
title; together with the condition which has been called melanotic; 
and that which has been so well described by Laennec, under the 
term " medullary cancer." It appears to me that Bayle was so far 
right, because when the lungs are thus affected, the individuals fre- 
quently emaciate, cough, and breathe in the same manner as in the 
tubercular disease. 

The following account of the more rare varieties of structural de- 
rangement found in the lungs, is compiled from Laennec's work: 

1st. Bodies of a cartilaginous, osseous, calculous, and creta- 
ceous nature. — Sometimes cartilaginous cysts are seen, containing 
bony or chalky concretions. Laennec states that the bony matter is 
not perfect, containing a greater quantity of calcareous phosphate, 
and much less gelatine than true bone, and hence these bodies re- 
semble a piece of stone more than bone. In some cases, he says they 
contain no gelatine, and resemble moistened chalk. There are also 
found points of ossificalion in various parts of the lungs. I have 
never seen them provided with cysts, which Laennec stales are very 
rare indeed; the non-encysted ossifications are those to which I now 
allude. They are sometimes very numerous; they feel rough and 
pointed, and are generally adherent to the pulmonary tissue, which 
is sometimes of a cartilaginous hardness. Lately I dissected a lung 
studded over with this kind of production ; each was surrounded 
with a melanotic mass, which, when situated on the surface of the 
lung, adhered to the pleura in such a manner as to prevent a sepa- 
ration. Sometimes they are observed in the bronchial glands. 

The chalky concretions are found in two states, one resembling 
soft chalk, the other like common mortar. In general, these are en- 
cysted. Sometimes calculous bodies, of the shape and size of small 



PHTHISIS PULMONALIS. 433 

peas, are not only found on the surface of the lungs, but are also oc- 
casionally expectorated, which leads many to suspect that they are 
formed in the bronchial tubes; it is more probable they are formed 
in the substance of the lungs, and find their way into the air-passages 
by ulceration or absorption. When meeting with these large bodies 
on dissection, I have always seen considerable disease in the surround- 
ing pulmonary tissue, sometimes in the state of recent inflammation, 
at others of gray or red hardening. I cannot sanction the opinion that 
these concretions are the product of powdery substances taken into 
the lungs, suspended in the air we breathe; but bronchitis is often 
produced in this manner. Laennec supports the same opinion, and 
his reasoning appears to be quite conclusive. He believes that these 
concretions are consequent to tuberculous affections that have been 
cured ; but I see no reason for agreeing with him. 

2d. Melanosis of the lungs. — These productions, in their early 
or crude state, "possess a consistence equal to that of the lymphatic 
glands, and a homogeneous and somewhat humid composition ; they 
are opaque, and in structure very much resemble the bronchial 
glands in the adult. When they begin to soften, a minute portion 
of fluid can be expressed from them, of a thin reddish character, 
intermixed with small blackish portions of a substance which is 
sometimes firm, sometimes friable, but which, even when friable, 
conveys to the touch an impression of flaccidity. In a more advanced 
stage, these portions first, and subsequently the whole mass in which 
they are contained, become quite friable, and are soon converted into 
a black paste. Melanotic matter is found in four different forms, 
encysted, non-encysted, generally infiltrated into the natural texture, 
and deposited on the surface of organs.''* 

Encysted melanosis.— "The cysts inclosing this species are very 
regularly rounded, and vary in size from that of a small hazelnut to 
that of a walnut. They have a very regular and equal thickness, 
which is never greater than half a line. Cellular substance appears 
to be the only tissue that enters into their composition. They adhere 
by means of a very fine cellular membrane to the substance of the 
organ Ifl Which they are situated, and from which they can be readily 
separated by dissection. Their interior surface is rather smooth, but 
adheres to the morbid (natter which it surrounds. The medium of 
this adhesion appears to be a very fine imperfect cellular tissue, 
though it cannot always be distinguished. I have hitherto (says he) 
only found this variety of melanosis in the liver and lungs; and in 
the latter organ I have only as yet met with a single mass of it."t 

/ r nencysted melanosis.—" Tins variety is much less rare than the 
preceding. I have met with it (he says) in the lungs, the liver, the 
pituitary gland, and the nerves j hut it has been since found in almost 
every organ. The volume of masses of this kind is quite indeter- 
minate, varying from that of a millet seed to that of an egg, or more. 
They are also quite irregular in figure. They commonly adhere 
very closely to the parts in which they are .situated ; sometimes, 
however, they are united to these by a very fine, though sufficiently 

• Forbcs's Laennec, p. 3H3. t Laennec, p. 383. 

37 



434 PHTHISIS PULMONALIS. 

visible, cellular tissue, which permits their removal without any lace- 
ration. In this last case they are commonly of a rounded shape."* 
Melanotic matter generally infiltrated into the natural texture. 
— "It frequently happens that this morbid matter, in place of being 
segregated in distinct masses, is disseminated throughout the organs 
in which it is found, and deposited between the particles or molecules 
of the natural tissue. The appearance and colour of parts affected 
in this manner present a good many varieties, according to the tex- 
ture of the organ, the quantity of matter deposited, and the particular 
condition of this matter. When the infiltration is recent, and in 
moderate quantity, the appearance of the affected part merely differs 
from the natural condition, in being intermixed with small black dots 
or striae, the intermediate portions being quite of a healthy character. 
As the disease increases, the dots and striae enlarge in number and 
volume, until the whole of the natural tissue of the part is lost in the 
morbid degeneration. It is usually only at this period of its progress 
that the melanosed matter begins to soften ; but if the softening takes 
place before the complete removal of the natural tissue of the part, 
it frequently happens that this softens also, and intermingles with the 
morbid matter, the colour of which is thereby changed to brownish, 
yellowish, or grayish." 

There are various preparations in my museum, which illustrate 
these very excellent descriptions of M. Laennec. There is one, 
showing the last variety of this affection, which was found in the 
stomach of a dram-drinker. I have also the portion of a lung, the 
whole of which was affected with the disease, and which looks like 
a sponge filled with very black ink. There is also a rare specimen 
of melanosis affecting the pleura pulmonalis. 

A case, rapidly fatal, occurred to me in 1825. The subject was 
a middle-aged man, who began to complain on the 15th July, but did 
not take medical advice till the 19th, when he was found to complain 
of severe pain and weight in his head, some ringing in his ears, but 
no intolerance of light; the pain was increased by motion and cough- 
ing; his breathing somewhat accelerated, respiration 24 in a minute ; 
but he had neither pain, cough, nor expectoration ; complained of 
uneasiness in the abdomen, which was not increased on pressure ; 
tongue whitish in the centre, and at the edges red ; skin hot and 
dry; pulse 90, full and strong. Twenty ounces of blood were 
taken without any decided relief, and in five hours afterwards, 
twelve ounces more, which removed the headache. On the 20th, 
he was so much better as to be able to leave his bed, but became 
worse again towards evening. 21st. Again somewhat improved. 
By the stethoscope, the respiration was noisy and blowy, which led 
to a suspicion of the existence of crude tubercles, surrounded by 
healthy structure; respiration 30; pulse 112; tongue not improved; 
face somewhat flushed; skin hot and dry. He died next morning 
in what his friends called <• a fit," which appeared to be asphyxia. 
The lungs were found completely infiltrated with melanotic mat- 

* Laennec, p. 384. 



PHTHISIS PULMONALIS. 435 

ter, but still crepitating; and they floated when placed in water ; the 
spleen was affected in the same manner.* 

3d. Medullary sarcoma. — According to Laennec, " medullary 
sarcoma may exist under three different forms, viz.: 1st, encysted; 
2d, in irregular masses without a cyst ; and 3d, diffused in the tissue 
of an organ. In whichever of these forms it exists, it presents, in 
its progress, three different and distinct stages, viz. 1st, the incipient 
or crude state ; 2d, its perfect state, in which it exhibits the resem- 
blance to brain, which forms its special characteristic; and 3c/, its 
soft or dissolved state. 

u I shall first describe it as it is observed in the second or perfect 
state, as this is the condition in which the three varieties most nearly 
resemble each other, there being much difference between them in 
the first and last stages. In its perfect state it is homogeneous, of a 
milky whiteness, and very like the substance of the brain. In differ- 
ent parts it has commonly a slight rose tint. It is opaque when ex- 
amined in mass, but in thin slices it is in a slight degree semi-trans- 
parent Its consistence is like that of the human brain; but it is 
commonly less coherent, being more easily broken and comminuted 
by the finger. According to its degrees of density, it resembles one 
part of the brain more than another; but it is more commonly like 
the medullary substance of a brain that is more ordinarily soft (or 
like that of a child's) than the healthy brain. When existing in 
any considerable extent, this species of cancer is, in general, supplied 
by a great many blood-vessels, the trunks of which ramify on the 
exterior of the tumours, or between their lobes only, while the mi- 
nuter branches penetrate their substance. The coats of these vessels 
are very fine, and readily ruptured ; and this accident gives rise to 
clots of extra vasated blood in the interior of the tumours, sometimes 
of considerable size, which bear occasionally a striking resemblance 
to those found in the brain of subjects dead of apoplexy. Extrava- 
sations of this kind may sometimes be so considerable as to supplant 
almost the whole of the brain-like matter, so that the true nature 
of the tumour can only lie ascertained by some small points, still 
remaining of the original growth. This change occurring in super* 
ficial tumours of tins kind, and being productive of nnuli lia-mor- 

hage, appe irs to me to have given rise to the name of Fungus h;v- 
matode*, applied to certain cancers by modem surgeons. Under this 
Dame, however, I am also convinced that they have confounded tu? 
motirs of different Kinds, especially those commonly called varicose, 
which are composed of an accidental tissue, very analogous to thai 
of the corpus cavernoaum penis. I have never observed any lym- 
phatics in tumours of this sort, but it is probable that the circulating 

(• In tin- splendid work of Dr. Carswell, " Illustrations of the elementary forms of 
• reader will find an admirable riew of ever; form and variety ofmela- 

aftion I shall merely quote • or tun facts respecting t he 

ebemleal characters of true melanosis, which Dr. Carawell, however, calk melanoma, 

Mel tic ter is essentially eon ; 1 of the colouring matter of tlie blood, unit- 

1 Shrine, (both <>{ them in a particular su:<-,) three kinds of tatty mailer, and 
phosphate <>i tunc and iron. 
1 .on Inclined to believe thai melanosis i- of leaa frequent occurrence in il><' United 
Sialic than in Bart pe, In my 11 leeti ma li lias occurred with extreme rarity,] 



456 PHTHISIS PULMONALIS. 

system is complete in them, as I have seen their substance deeply 
tinged with yellow in cases of icterus. The matter of encephaloid 
does not continue long in the state just described; it tends incessantly 
towards a softer condition, and, in a short space, its consistence 
scarcely equals that of a thickish paste. Then begins the last stage : 
the process of softening becomes more rapid, until the morbid mat- 
ter becomes as liquid as thick pus, still, however, retaining its whit- 
ish or rosy white tint. Sometimes, at this period, or a little earlier, 
the blood extravasated from the vessels contained in the tumour, be- 
comes intermixed with the morbid matter, so as to give it a dark red 
colour, and the resemblance of clots of pure blood. In a short time 
the extravasated blood is decomposed ; the fibrine concretes, and, to 
gether with the colouring matter, unites with the brain-like matter 
of the tumour ; and the serum is absorbed. In this condition the mor- 
bid growth retains no resemblance to brain; it is of a reddish or 
blackish colour, and of a consistence like that of paste, somewhat dry 
and friable. Sometimes the change of structure and appearance is so 
complete, that one would be led to consider the tumours as of a dif- 
ferent kind, but for the existence in thern of portions of the original 
matter still unchanged. In some cases, contemporaneously with tu- 
mours that have changed in this manner, there will be found others 
retaining the original cerebral character; so that, in all cases, we are 
able, with a little practice, to discover the true nature of the tumour 
in all its stages."* 

" Such are the characters which this species of cancer presents in 
its two latter stages, and equally in all the three varieties. I shall 
now describe the characters of each of these varieties in the first or 
crude state. 

" 1. Encysted medullary sarcoma. — The size of this species is 
very various. I have seen the tumours as small as a hazelnut, and 
larger than a middle-sized apple. I have found them as large as 
this in the lungs. The cysts are of pretty equable thickness; and 
this is never more than half a line. They are of a grayish-white, 
silvery, or milky colour, and have a semi-transparency, more or less, 
according to their thickness. Their texture is altogether cartilagi- 
nous, and rarely fibrous; but it is much softer, and less easily broken 
by bending, than cartilage; on this account they must be ranged 
among the imperfect cartilages. The medullary matter contained 
in these cysts can be easily detached from their inner coat. It is 
commonly divided into several lobes, by a very fine cellular tissue, 
which may be compared with the pia mater, and the more so from 
the great number of blood-vessels which traverse it. The fineness 
and brittleness of these have been already noticed, and also their 
penetration of the cerebriform matter itself, to which they give a rose 
lint here and there. It is their rupture that gives rise to the clots 
of blood formerly mentioned. Sometimes, also, the trunks of these 
vessels are ruptured in the interstices of the lobules ; and the blood 
being injected beneath the fine cellular substance which accompanies 
them, gives this the appearance of a distinct membrane. It is com- 

* Forties's Laennec, p. 393. 



PHTHISIS PULMONALIS. 437 

monly in their early or crude stage that these tumours are divided 
into distinct lobes. These are especially observable on their surfaces, 
and have sometimes considerable resemblance to the convolutions of 
the brain. The cyst does not at all enter between these convolutions, 
nor does it even indicate on its surface their place or configuration. 
In this stage the medullary matter is pretty firm, often firmer than 
the fat of bacon. It is of a dull white, pearl gray, or even yellowish 
colour, and, in thin slices, has a slight degree of semi-transparency. 
When cut into, it appears subdivided interiorly into lobules, much 
smaller than those seen on its surface. These lobules are in such 
close contact as to leave no interval whatever; and their separation is 
merely indicated by the reddish lines traced by the vascular cellular 
tissue by which the separation is effected. These lines rarely cross 
each other, butexhibit many irregular curves and convolutions. When 
these tumours pass into the second stage, their texture becomes more 
homogeneous, and all distinction of the small interior lobules is quite 
lost; the distinction, however, of the larger exterior lobes still con- 
tinues. The blood-vessels, which run between these lobes, and in 
the cellular tissue immediately investing the tumour, are much more 
developed than in the early stages of the disease, and it is only at 
this second stage, or as it approaches the third, that the extravasa- 
tions of blood take place. The third stage begins, as I have already 
mentioned, when the medullary matter has acquired a consistence 
like pap or paste, or like that of a brain softened by commencing 
putrefaction. In this state, it has still much resemblance to cerebral 
su!i stance. I have never found that the morbid growth ever softens 
still more, or that it is absorbed or evacuated, so as to leave an empty 
cyst or cavity like tubercles; consequently, it is not probable that we 
shall ever find pectoriloquism as a sign of this affection. Hitherto 
I have only found these encysted medullary tumours in the lungs, 
Uver and cellular substance of the mediastinum."* 

••j. Unencysted medullary sarcoma. — Medullary tumours of 
• are very frequently met with. Their size is very variable. 
I have Been them from the size of the head of a full-grown foetus to 
that of a hemp-seed. Their shape is commonly spheroid, but occa- 
illy flattened, ovoid, or altogether irregular. Thru- external 
. but the divisions are less regular than in the 
encysted species; their internal structure, in the two last stages, is 
precis* ly the s ime. The cellular membrane, which invests them, is 
mi. i . irked, according as they arc placed in a loose cellular 

tissue, or in the Bubstance of a viscus of firm texture: in the latter 
i, their investing membrane is thinner and less distinct. In their 
first or crude Btage, their semi-transparency is greater than after- 
wards; they are almost colourless, or have a very slight bluish tint 
in ocellated patches; they are pretty haul, and divided into numerous 
lobes. Their substance is then fatty, like lard; but when incised, it 
not at all grease the scalpel, and it coagulates by heat, without 
showing a particle of fat. 
The transition from the first to the second stage takes place in the 

• 1 i . 



438 PHTHISIS PULMONALIS. 

following manner: — The substance of the tumour becomes more opa- 
que, softer, whiter ; and its inner distinction into lobules, for the most 
part, disappears. The original texture is observed longest in the 
neighbourhood of the external interlobular fissures. In this situa- 
tion, I have found portions still in a state of induration, after the 
mass of the tumours had passed into the third stage. I am led to 
conclude that the encysted tumour follows precisely the same pro- 
gress as that just described. The non-encysted medullary tumours 
may exist in any part of the body; but they are most frequently met 
with in the loose and abundant cellular tissue of the limbs, and in the 
larger internal cavities. I have met with them in the cellular mem- 
brane of the forearm, thigh, neck and mediastinum ; they are still 
more frequently found in the cellular substance around the kidneys, 
and the anterior part of the spine ; and in these situations they often 
have a very large size. Although they are frequently found in the 
viscera, they are, however, much rarer there than in the cellular sub- 
stance.'' * 

In my collection there are several fine specimens of all these varie- 
ties of medullary sarcoma, and others unnoticed by any author, but 
which it would be tedious to describe. 

* Forbes's Laennec, p. 397. 



CHAPTER VII. 
ASTHMA. 



This term was formerly used to express every species of difficulty 
of breathing. Latterly it has beeu employed to signify a specific 
intermittent dyspnoea, independent of organic lesion; but I shall show 
how erroneous such views of this disease are when I come to treat 
of its pathology. 

This disease is observed most frequently in people beyond the 
middle age, rarely in youth; it affects men oftener than women, and 
those of full habit of body more frequently than the spare; and it 
would seem to be occasionally hereditary. 

Phenomena. — Attacks of asthma sometimes appear towards the 
afternoon, or at the moment the patient is going to bed, but more fre- 
quently they occur during the night ; occasionally, indeed, the patient 
Is seized during a sound sleep, and awakes with a sense of suffoca- 
tion. In describing the disease, I shall confine myself to a few of 
the leading symptoms, because, depending upon so many morbid 
conditions of the lungs, heart, and perhaps the brain, the symptoms 
winch may take place, have too wide a range of character to be 
taken into a short general sketch. Upon the approach of a paroxysm, 
the patient usually feels a sense of coldness over the surface of the 
body, indeed sometimes severe rigors take place; a sense of constric- 
tion ifl experienced in the chest and difficulty of breathing, both of 
which are increased in the recumbent posture. He sits up, because 
he Can then breathe more easily; he demands more air to be admitted 
into the apartment ; he employs all his efforts to dilate the chest, and 
then to empty the lungs. There is restlessness; occasional cough, 
which the patient makes efforts to perform, thinking to force some- 
thing out of the I ungs which impedes his breathing. Expiration 
II performed with a peculiar whistling sound, and sometimes it is 
sonorous. The face is either pale or livid. The eyes have an anxi- 
ous expression. The extremities are frequently cold, even the nose 
and the •mis; and the face and breasl are covered with a cold dew. 
The pulse is in various States— full and quick— small and quick — 

sometimes opprec ed— and it occasionally intermits. The skin is 
frequently discoloured; and there are often a troublesome flatulency 
and sense of fulness in the abdomen. These symptoms continue with 
more of less violence for some hours or days till expectoration takes 
place. Which generally precedes ■ remission. The expectoration is 

sometimes scanty, at others 'copious. This is a short description of 



440 ASTHMA. 

the symptoms as they generally occur. In slight cases, however, a 
sense of constriction in the chest only is complained of, which is 
sometimes relieved by the expectoration of a whitish mucus; but in 
more severe instances, the symptoms are much more violent and 
alarming, not only to the patient, but to the bystanders; instant suffo- 
cation being threatened, he solicits relief in the most urgent manner. 
A remission sometimes takes place immediately after the occurrence 
of profuse perspiration, and occasionally after a copious discharge of 
urine. 

An individual may have an attack for three or four successive 
nights, and not be again affected for months; sometimes it returns 
every month for a number of years, and then disappears for a con- 
siderable time. Women are generally attacked immediately pre- 
ceding the catamenia. The duration of each paroxysm is very 
various, from two or three days to three or four hours. One attack 
leads to another, and the paroxysms generally become more and 
more frequent and severe. 

In describing this disease, authors have mentioned two varieties 
— the humid and the dry. The first commences more gradually, 
and becomes slowly worse ; the cough is frequently severe, attended 
with early and copious expectoration, which produces relief; the 
mucous rale is heard almost from the beginning. The dry asthma 
commences suddenly, and becomes quickly severe, but does not con- 
tinue long. The cough is slight ; the expectoration very scanty, and 
observed at the close of the paroxysm only ; the mucous rale is not 
heard till towards the conclusion of the attack — even then it is very 
slight and, perhaps, partial. 

Causes. — Asthma is liable to return occasionally during the whole 
period of a man's life. The subsequent attacks depend on different 
circumstances in different constitutions. Some are affected by ex- 
ternal heat, others by external cold; many by eating indigestible 
substances, or by overloading the stomach ; and almost all asthmatics 
are affected by hurried exercise, and by any other cause that increases 
the rapidity of the circulation. It will generally be observed, that 
those who are predisposed to it, dread cold, moist weather, and 
stormy seasons. Individuals who follow particular occupations, 
would seem to be more subject to this affection than others, particu- 
larly those who are exposed to irritating vapours, and breathing an 
atmosphere in which different substances, in very fine powder, are 
suspended. Causes particularly affecting the nervous system, would 
also seem to be capable of producing paroxysms, such as passions of 
the mind, &c. 

Pathology. — It is generally admitted, that that kind of dyspnoea 
which is now under consideration, and which is commonly known 
by the name of asthma, is produced by various diseased states of the 
lungs and heart. Chronic bronchitis, emphysema and congestion 
are the three conditions of the lungs which most frequently produce 
asthma; and I believe it is likewise occasioned by some kind of 
nervous irritation, the nature of which is yet unknown. It is, per- 
haps, from this view, that the doctrine of a spasmodic structure in 
the air-tubes has arisen. 



ASTHMA. 441 

Having already treated of chronic bronchitis, it is unnecessary to 
say more upon the subject in this place ; I shall therefore proceed to 
describe Emphysema of the lungs, of which there are, according to 
Laennec, two kinds: l.\7. That which consists in the simple dilatation 
of the air-cells, which he calls pulmonary or vesicular emphysema; 
and 2d. That which is characterized by infiltration of air between 
the lobules of the lungs, which lie terms interlobular emphysema. 
In the first, the size of the vesicles is much increased, and also less 
uniform ; the greater number equal or exceed the size of a millet- 
seed, while some attain the magnitude of cherry-stones, or even 
French beans. The largest are, in all probability, produced by the 
union of several of the air-cells, in consequence of the rupture of the 
intermediate partitions ; sometimes, however, they appear to arise 
from the simple enlargement of a single vesicle. The bronchial 
tubes, especially the small ramifications, are sometimes very evi- 
dently dilated in those portions of the lung where the emphysema 
exists. 

interlobular emphysema, according to the same author, is 

icterized by infiltration of air between the lobules of the lung, 
and must be considered as necessarily depending on a rupture of 
some of the air-cells in the fust place, and the consequent extravasa- 
tion of the air contained in them. When the extravasation exists 
Dear the root of the lungs, it sometimes extends to the mediastinum, 
thence crosses to the neck, and occasionally spreads over the whole 
subcutaneous and inter-muscular cellular substance of the body. 
The pathognomonic signs of the pulmonary emphysema, says 
linec, "are furnished by a comparison of the indications derived 
from percussion and mediate auscultation. The respiratory sound 
U inaudible over the greater part of the chest, and is very feeble in 
the points where it is audible; at the same time, a very clear sound 
IS produced by percussion, from time to time, also, we perceive, 
wlm / dm respiration or cough, a slight sibilous rattle, or 

i of (he valve, as in the dry catarrh, occasioned by the displace- 
ment of th'- pearly spina." When existing in a high degree it may 

cognized by a silmi which is altogether pathognomonic, which 
I. the crepitous rattle with large bubbles. "In this case, 

ound, during inspiration of coughing, is like that which would 
!)•• produced by blowing into half-dried cellular substance."* 
In tin- Interlobular emphysema, Laennec assures us, •• there is one 
pathognomonic, viz.: the dry crepitous rattle with 

. Ainu very distinct and continuous, or nearly so. To- 

r with this sign, (continues he,) we usually perceive, during 

ration and expiration, a sound or sensation as of one or more 

bodies rising and falling, and rubbing against the ribs.' 1 

Bmpliy jera i of the lungs is a common disease in horses, ami is the 

"i .\iiii is called broken-wind; and i^ more common in 

in in id in is generally imagined. It is produced by various causes, 

ignis it occurs during the act of bearing down 

in labour; but mora frequently it is a consequence of violent cough- 

• r | ion, p, r,~ 



442 ASTHMA. 

ing in cases of bronchitic inflammation; indeed, I have scarcely ever 
witnessed a dissection of a person who died of bronchitis or hooping- 
cough, without seeing pulmonary emphysema. 

For a more particular account of these morbid states, the reader is 
referred to the work of Laennec. 

There cannot be a doubt that the nervons system has a powerful 
influence on the functions of the lungs, when labouring under dis- 
ease, as well as in health ; and I imagine no one can deny that asth- 
ma may be produced, either in consequence of some diseased action 
in the brain, or in the nerves themselves which supply the lungs. It 
has been attempted to be shown by Reisseissen and Laennec that 
the bronchial tubes possess a muscular structure, through the agency 
of which the air-vessels contract, when under the influence of spasm; 
but this is not a new idea on the part of Reisseissen or Laennec, for 
Cullen makes the following statement: — " From the whole of the 
history of asthma, now delivered, I think it will readily appear, that 
the proximate cause of this disease is a preternatural, and, in some 
measure, a spasmodic constriction of the muscular fibres of the bron- 
chise, which not only prevents the dilatation of the bronchiae neces- 
sary to a free and full inspiration, but gives also a rigidity which 
prevents a full and free expiration." — (Par. 1834.) But neither is 
this an original idea of Cullen's, for it was entertained long before 
his time by Hoffman and Willis. It is foreign to the object of this 
work to enter into anatomical controversy, and unnecessary in this 
instance, for even Laennec states that he had " met with only a very 
small number of asthmatics in whom there was evidence of pul- 
monary spasm, without any attendant catarrhal affection; but some 
few I have met with. On the other hand, I have known a great 
number of patients, in whom the catarrh, whether dry, pituitous, or 
mucous, was too slight in degree, or too small in extent, to be consi- 
dered as the real cause of this asthma." — (Page 412.) Because, 
perhaps, there might be, in these cases, some organic lesion of the 
heart and large vessels, or the coexistence of cerebral irritation. 
These observations lead me to remark, that there is almost always 
something more in this disease than the original organic lesion in the 
lungs themselves; this experience has frequently led me to trace to 
sudden congestion of the lungs, which flattens the air-vessels, and 
prevents them from dilating. 

Various diseases of the heart produce asthma; the most frequent 
are dilatations of its cavities, diseases of its valves; and aneurism of 
the aorta, of which more hereafter. 

Treatment. — From want of attention to the pathological condition 
of the body, the treatment of asthma has hitherto been uncertain and 
empirical. Some highly extol one remedy, and some another; some 
always use the lancet, and others invariably condemn it. Although 
an advocate for occasional bleeding in asthma, yet I am convinced 
that no remedy, except the indiscriminate use of opium, has done 
more mischief. There are two circumstances only in which bleed- 
ing should be had recourse to: 1st. Where we have evidence of acute 
action in any tissue of the lungs, superadded to any of the organic 
lesions already mentioned ; 2d. When there is much venous engorge- 



ASTHMA. 443 

ment of the lungs. In old chronic cases, it must always be a doubt- 
ful, and occasionally, a dangerous remedy. Dr. Bree assures us, that 
he repeatedly tried bleeding, but does not think the paroxysm was 
ever shortened an hour by the remedy; and in old people he found 
it injurious. It may be mentioned, that Dr. Bree was himself an 
asthmatic, and after paying much practical attention to the'disease, 
he wrote a treatise upon the subject, which is worthy of perusal. 
Bleeding must be employed early in the paroxysm, or not at all, un- 
less the patient is threatened with suffocation. The pediluvium is 
to be instantly had recourse to, which I have known to arrest a 
paroxysm; as well as inhaling the vapour of hot water. The apart- 
ment is to be freely ventilated, and too many people are not to remain 
in the room. Laxatives are always necessary, as confined bowels 
aggravate the complaint. Vomiting is a favourite remedy with many, 
and is useful principally in two cases — when there is evidence of a 
load of food being in the stomach — and when we know that the 
disease depends upon chronic bronchitis. In the last case, vomiting 
will assist in clearing the air-passages of superabundant mucus. In 
almost all cases, contra-irritation is useful, whether produced by 
mustard plasters, stimulating embrocations or blisters. Strong col- 
fee was formerly recommended by Sir John Floyer, from the relief 
he experienced in his own person, and it has since been highly lauded 
by his fellow-sufferer, Dr. Bree. With respect to opium, very oppor' 
site opinions have been maintained. Lacnnec speaks strongly in 
favour of the whole class of narcotics, with a view of producing sleep, 
upon the theory of bringing patients so affected as nearly as pos- 
sible to the level of bats, and other animals, which hybemate, and 
consume nearly a hundred times less air when in a state of torpidity. 
He seems to' have been influenced by an idea of producing relaxa- 
tion of the muscular fibres of the air-tubes, thereby overcoming the 
spasm of the lungs. The following narcotics are recommended by 
Laennec — opium, belladonna, stramonium, phellandrium aquaticum, 
aconitum napellus, colchicum, tobacco smoked or taken internally, 
cicuta, dulcamara, hyoscyamus. With respect to tobacco, it may be 
mentioned, upon the authority of Dr. Ferriar, that Baglivi used the 
ujiulapum t abaci" in casus of asthma.* 

Ii (in- disease generally depended on spasm, opium should be use- 
ful in a great number of cases; but I am convinced, from what I 
bare Been in practice, that it is the most dangerous of all the reme- 
dies which have hitherto been recommended. Dr. Bree tells us that 
four grams nearly sent him into the next world. In truth, it is a 
remedy Which must very often interfere with the, efforts of the con- 
stitution for relieving the patient; more particularly in that form of the 
disease produced by chronic bronchitis, when opium, by allaying the 
cough, promotes a collection of mucus in the air-passages: hence 
the common observation, thai opiates dry up the expectoration. I 
havr seen tome individuals very much relieved by smoking tobacco, 
ami some by smoking stramonium. 

An ili«: disease is frequently observed to terminate by expectora- 

• Reflections, p. 20-1. 



444 ASTHMA. 

tion, the class of medicines called expectorants has been much em- 
ployed. In fact, if routine practitioners were asked what should be 
done for a patient in a fit of asthma, they will be found either to 
order bleeding, or to give an expectorant. 1 have seen them often 
tried, but very seldom with any good effect. Of this class, squills is 
much in use, together with the foetid gums. 

[I have been much pleased with the use of the infusion of vale- 
rian; and when an expectorant is necessary, liquorice root may be 
added. Of all anodynes, that which has had the happiest effect in 
my experience is pure Hoffman's anodyne, given in full doses. In 
cases attended with a dry cough and great oppression, I have found 
signal relief to follow the application to the chest of a large poultice 
of flaxseed and hops, or bran and flaxseed. These ingredients 
should be mixed with hot water or hot vinegar, until the mass attains 
a proper consistence, when it should be enveloped in gauze or thin 
muslin, applied as warm as it can be borne, and renewed every three 
hours.] 

After the termination of the paroxysm, tonics are frequently re- 
commended. Dr. Bree speaks much in praise of a remedy com- 
posed of nitric acid, hyoscyamus and squills. Some tell us to avoid 
warm bathing, and to use the cold bath as a tonic during the inter- 
vals ; the cold bath agrees with some better than the warm, and I 
have seen both do much mischief. [I have known great benefit to 
be derived from frequently bathing the feet in hot salt and water; 
but to be serviceable during the paroxysm, the bath should be pro- 
tracted for at least half an hour.] 

Issues, setons and cauteries have all been used as contra-irritants, 
and it is worthy of remark, that many fits of asthma have taken 
place immediately after the disappearance of a cutaneous eruption. 
I have myself witnessed examples of this kind, and I have been 
acquainted with asthmatics who were occasionally affected with 
cutaneous eruptions, and who, although they complained of much 
distress from the itching and tingling of the skin, were yet contented 
with their lot, and invariably expressed themselves as being certain 
of an attack of asthma if the eruptions were repelled. The obser- 
vation of such circumstances has led me to insist much on the pro- 
priety of employing contra-irritation in all diseases of the chest, but 
particularly in those of a chronic nature. 

The subcarbonate of iron has been recommended, but I cannot 
speak from experience of its effects. 

A very dangerous complication of asthma with anasarca occa- 
sionally takes place; the routine practitioner amuses himself and 
distresses his patient, by " pumping out the water." But I cannot 
too strongly condemn this as a general practice, because the reme- 
dies weaken, sometimes hasten the fate of the patient, and do not 
reach the root of the evil. 

Galvanism is another remedy which has been much lauded, not 
only in this country, but on the continent. Dr. Wilson Philip, to 
whose exertions in endeavouring to improve the science of medicine, 
the profession stands deeply indebted, directed his attention to this 
subject. He made many experiments on animals, in conducting an 



ASTHMA. 445 

inquiry into the laws of the vital functions ; and among others, he 
divided the pneumogastric nerves, in order to diminish the nervous 
influence in the lungs and stomach ; the digestive powers were found 
to be thereby much impaired or suspended, and dyspnoea was pro- 
duced. He then directed galvanic influence towards the lungs and 
stomach, and he observed that the animal could be made to breathe 
easily, and digest its food. After these experiments had been re- 
peated and confirmed, Dr. Wilson Philip was naturally led to inquire 
what diseases depended on a failure of the nervous influence. Judging 
from analogy and observation, he thought it probable that indigestion 
and asthma were two, at least, of the number. This is a short view 
of the circumstances which led Dr. Wilson Philip to expect relief 
from galvanism in habitual asthma; which name he has given to 
that form of the disease, in which the breathing is constantly op- 
pressed — better and worse at different times, but never free — and 
often continues to get worse in spite of every means we can employ. 
He states that lie used galvanism in many cases, and almost uni- 
formly with relief, applying as much of the galvanic influence as 
patients could easily bear. The period varied from five to fifteen 
minuies before relief was experienced ; and he generally found, that 
the stronger the sensation excited, the more speedy the relief; he 
found from eight to fifteen four-inch plates of zinc and copper suffi- 
cient ; the fluid used, was one part of muriatic acid to one hundred 
and twenty of water. Some people required more than sixteen 
plates, and a few could not bear eight. It is a curious fact, that on 
the first application of galvanism, a person may experience little sen- 
sation from the operation of twenty-five or thirty plates, yet after- 
wards he may not be able to bear more than six or eight. He ap- 
plied it in the following manner :— he placed two thin plates of metal 
dipped in water, one on the nape of the neck, the other on the lower 
part of the epigastric region. The wires from the different ends of 
ih'' trough were brought in contact with the plates; in this way the 
galvanic influence was sent through the lungs, as much as possible in 
the direction of the nerves. The operation was discontinued as soon 
SI the patient Baid his breathing was easy, any further application 
being found quite unnecessary. We are assured that this means 
afforded relict to those who had laboured under oppressed breathing 
for ten or twenty years, sa readily as in more recent cases; therefore, 
we must join Dr. Wilson Philip in taking this as a proof, that no or- 
ganic lesion existed in the lungs. For further information on this 
interesting topic, the reader is referred to his work, entitled " Inquiry 
Into the Laws of the Vital Functions."* 

Whatever differences of opinion exist respecting the nature and 
M'at "i asthma, and the treatment propel t<> be pursued during a 

paroxysm, all agree in recommending, that the diet of an astheinatic 
should he light. Sufficiently nourishing, and easy of digestion; his 
Clothing warm ; and thai he should avoid exposure in cold, damp 
Weather, particularly when the wind is m the east. The bowels 

[• Aniithi-r nml :i i in i ■!•• i iinnk- ul npplyii)^ ihc galvanic lluid will be mentioned 
under tlir head of Epilepsy.] 
38 



446 [PULMONARY (EDEMA.] 

should be kept easy; but it is proper to mention, that I have known 
a paroxysm brought on by hypercatharsis as well as constipation. 

[M. Aboussohn, in a recent memoir, has shown that worms some- 
times infest the air-passages, giving rise to extreme distress, and to 
death itself. The worm, in every instance, has been found to be the 
ascaris lumbricoides, which, no doubt, passes from the oesophagus 
into the trachea. The above author cites six cases, and adds, " that 
there were five in which the accident happened to children between 
eight and nine years of age, four of whom were girls ; the sixth case, 
however, proved that it may happen in advanced years, (the patient 
having been 52 years old) when circumstances are favourable to the 
development of worms. The symptoms differ according to the 
situation of the worm : when it was in the larynx, the violent pa- 
roxysms of cough threatened suffocation ; when in the trachea, the 
cough was less intense; there were rather dyspnoea with paroxysms 
of orthopnoea, and great agitation, vomiting, and incontinence of 
urine. Death was preceded by convulsions in one case, and in ano- 
ther was sudden, as if the lung, fatigued by the struggle, was deprived 
of all nervous influence. The impression of the patient, that a fixed 
and local obstacle prevents his respiration, is a valuable diagnostic 
sign. The means to be employed would be, 1. Immediately to pass 
the finger into the throat to examine if a worm can be felt, and to 
remove it. 2. Vomiting should be excited. 3. As a last resource, 
tracheotomy should be performed."*] 



[PULMONARY (EDEMA. (EDEMA PULMONUM.] 

[This is an effusion into the cellular tissue of the lungs; when cut 
into, these organs pour out a frothy serum, are heavier than natural, 
and pit under the finger. This form of dropsy often accompaniesgeneral 
anasarca, and especially when the latter is a sequel of scarlet fever. 
The symptoms are cough, dyspnoea and serous or other mucous ex- 
pectoration; but there is no mode of diagnosis, not even that derived 
from auscultation, which is not liable to some fallacy; because the effu- 
sion is usually a mere consequence and concomitant of other morbid 
states which mark this particular condition. The sound on percus- 
sion is, of course, more or less diminished in clearness and duration; 
while the respiration, as heard by the stethoscope, is harsh, bronchial, 
blowing and unequal or circumscribed. The heart's sounds are 
transmitted with undue intensity. t 

The treatment of this form of dropsy must depend on its cause and 
the attendant circumstances; but should the dyspnoea be urgent and 
sudden, immediate cupping between the shoulders and blistering to 
the chest in front, with a hot, saline pediluvium, will constitute the 
most available treatment.] 

[* Brit, and For. Med. Rev., No. 3, 1836.] 
[t Walshe. Physical Diagnosis, p. 133.] 



PAET IV. 



DISEASES OF THE CIRCULATING SYSTEM. 



CHAPTER I. 



GENERAL REMARKS ON DISEASES OF THE CIRCU- 
LATING SYSTEM. 



Diseases of the heart, from their frequency, and the extreme seve- 
rity of their symptoms, constitute a very important branch of practi- 
cal medicine. Till the conclusion of the last century, the generality 
of the profession were very imperfectly acquainted with them, and 
even now, when so much has been done by the labours of Corvisart, 
Laennec, Berlin and others, very erroneous notions prevail both 
with regard to their diagnosis and treatment. On this subject, our 
common systematic works are particularly deficient, and with the 
exception of the imperfect Treatise of the late Mr. Burns, no original 
work exists in English on this interesting and important class of dis- 
eases ; but it behoves me to mention, that the "original cases'' of 
Dr. Forbes are particularly deserving of attentive perusal ; and many 
valuable papers and cases are scattered through our periodical works, 
and the transactions of different societies. 

The utilities of the discovery of mediate auscultation by Laennec, 
in diseases of the lungs, have been already as fully discussed as the 
plan of the work will allow. Great advantage may also be derived 
from the employment of the stethoscope in diseases of the heart. 
Percussion affords us some assistance, but much less than in many 
of the affections of the lungs. Some physicians inform us, that the 
Stethoscope is entirely useless in affections of the heart, because, 
according to their account, we cannot distinguish between organic 
I nervous palpitation, which we confess we cannot always 
do by tli'- Stethoscope alone. These gentlemen seem to forget, how- 
ever, the impossibility of forming an accurate diagnosis by the com- 
mon signs or symptoms; and 1 may observe, that they might as well 
be required to give up the exercise of their profession altogether, as 
meet the important assistance which we derive by mediate auscult- 
ation, because it does not in all cases afford an absolute certainty. 

A common prejudice prevails, that as diseases of the heart are in 
1 1 i'M r nature irremediable, therefore an accurate diagnosis would only 
lead to despondency ami inertness "\' practice. Slethoscopists deny 
both the premises and the conclusion; and we insist, thai the more 
accurately we ere acquainted with the nature and seal of a disease, 
the more appropriate will he our practice. I can state, from cxperi- 
snee, that much may be done by judicious treatment, not only in 

■deviating, but in some cases in curing, diseases of the heart. We 

38* 



450 GENERAL REMARKS ON DISEASES 

have seen patients labouring under disease of the heart, pronounced 
to be far advanced in consumption ; and others, with disease of the 
valves, treated for indigestion and gastric irritation ; and we have 
also seen patients labouring under enormous dilatation of the heart, 
in its last stage, who were laughed at, and treated for nervous or 
dyspeptic complaints, and recommended to avoid vegetables, and 
eat beef-stakes; who were urged to use exercise, when the very 
effort brought on severe dyspnoea, and a sense of suffocation. I shall 
content myself, at present, by stating one additional circumstance — 
that it is of the greatest consequence to be able to distinguish simple 
hypertrophy from dilatation of the heart, because I feel convinced 
the former is as capable of being cured as almost any other disease 
to which the animal frame is liable ; so that, if there were no other 
circumstances to uphold us, in making use of the stethoscope, as an 
additional means of diagnosis in diseases of the heart, this alone 
should induce every professional man of common feeling and ho- 
nesty, earnestly to set about acquiring the power of employing the 
instrument. I blush to confess, that I was formerly one of those 
who ridiculed mediate auscultation, merely because, on applying the 
stethoscope once or twice I could hear nothing; but after putting 
myself under the direction of Dr. Scott, I was able, in the course of 
a very short time, to discriminate between the sound produced by 
respiration in a healthy state of the lungs, and that in disease. 

The contractions of the heart give rise to very distinct sounds, 
which enable us to study with ultimate success the actions of that 
organ, and to detect any irregularity or deviation from its natural 
condition. Before describing the organic changes which the heart 
undergoes, it is necessary to give a very brief analysis of its natural 
action as heard and felt with the stethoscope. If we apply this in- 
strument to the region of the heart, and place a finger on the radial 
artery, a moment previously to the arterial pulse, the ear is sensible 
of a slight impulse, accompanied by a somewhat dull, but very dis- 
tinct sound. Immediately, and without any interval, a clear sound 
is perceived, resembling that of a valve, or whip, or the lapping of 
a dog. After this, there is a short but well-marked period of re- 
pose. 

In a healthy person, with a well-proportioned heart, and carrying 
a moderate quantity of flesh, the shock or impulse of the heart can be 
felt over, or very near, the cardiac region only. In persons who are 
thin, and the thorax narrow, the impulse is more extended, and may 
be felt over the whole of the sternum, and occasionally over the left 
side of the thorax. 

The sound can generally be heard over the left side, anteriorly, 
and under the clavicles, but more faintly as we recede progressively 
from the cardiac region. When more extended, it is heard suc- 
cessively in the following places: — 1. Left side anteriorly — 2. Right 
side anteriorly — 3. Left side posteriorly — 4. Right side posteriorly. 

The intensity of sound is progressively less in the order above 
mentioned ; but it must be recollected, that a condensed, or strongly 
compressed lung, transmits the sound better than a healthy one ; and 
when there is much wheezing, the sound of the heart is obscured. 



OF THE CIRCULATING SYSTEM. 451 

Therefore, in estimating the heart's action, we must always take into 
account the state of the lungs. 

When the heart can be heard in all the points stated, we may 
suspect that it is larger than natural, and that it is dilated ; for it may 
be stated generally, that a great extent of sound is a mark of thin 
panetes; and that a strong impulse, with a confined range of sound, 
coincides with hypertrophy, or increased thickness in the walls of the 
heart. 

By the shock or impulse, we mean the sensation of percussion 
which is communicated to the ear on applying it immediately to the 
chest, over the region of the heart, or through the medium of the 
cylinder of wood. The degree of impulse is inversely as the extent 
of the sound, and directly as the thickness of the walls of the heart; 
when these walls are very thick, the shock is often so great as to 
elevate the ear of the observer, and may be often perceived even 
through the garments. 

When the walls are very thin, no impulse is communicated, even 
when the sound is very loud. A strong impulse, then, is to be con- 
sidered as a characteristic of simple hypertrophy; — the absence of 
impulse, with increase of sound, as an indication of simple dilatation; 
— sound and impulse conjoined, point out the combination of hyper- 
trophy and dilatation. 

It lias been stated, that the action of the heart is accompanied by 
two distinct sounds, and one impulse ; that the first sound is dull and 
prolonged, and that the second, which immediately succeeds the 
other, is sharp and clear; after which there is an evident interval. 
Accompanying the first sound, there is a shock or impulse felt by 
placing the hand over the region of the heart, which is not synchro- 
nous with the pulse at the wrist. Much diversity of opinion exists, 
and considerable discussion has lately taken place, as to the causes 
of the impulse and sounds, as well as respecting the rhythm or order 
of contraction of the different cavities of the heart; and it appears 
that the opinions of Laennec upon these physiological points are 
erroneous, and must be abandoned. Laennec supposed that the first 
soond is produced by Lbs contraction of the ventricles, the second by 
thai of tin; auricles; bill Mr. Turner has shown, in a paper published 
in tli'- 3d vol. of lb'- IM. Med. Chirur. Transactions, that the con- 
traction of the auricles always precedes thai of the ventricles; thus 
reversing the almost universally received opinion of the order of the 
Contraction of (he different cavities of the heart. Mr. Turner states 
that the contraction of the auricles is so immediately succeeded by 
thai of the ventricles, thai he found it very difficult, if not impossible, 
to distinguish any interval between them. He thinks, therefore, that 
the first sound i-, occasioned i>y the almost simultaneous contraction 
of both sets of cavities. 

Caute of tlo- first sound (mil impulse. — It is proper to mention, 
in tins place, that tin- sounds produced by the heart's action are not 
dependent on the contraction <>r relaxation of the muscular fibres of 
that organ, but are ore tsioned by the motion of the blood on the un- 
even Mil lac- of the cavities of the heart ; the intensity of the sound 
being increased by the rapidity of the motion, the roughness of the 



452 GENERAL REMARKS ON DISEASES 

surface over which the blood passes, and the thinness of the muscu- 
lar structure of the heart. On this point Dr. William Stokes, of Dub- 
lin, and Mr. Spittal are agreed. After a careful review of all the 
writings on this subject, and frequent examinations of the action of 
the heart by auscultation, I believe Dr. W. Stokes's view to be correct, 
that the first sound and its accompanying impulse, are produced by 
the motion of the blood propelled into the ventricles by the contrac- 
tion of the auricles. M. Magendie states, that the two sounds of 
the heart are owing to the successive imputation of the apex and side 
of the heart against the thorax, and that they are quite unconnected 
with the motion of the blood, or condition of the valves. He further 
states, that in hypertrophy of the heart to such a degree as to leave 
no space between the heart and ribs, there is no impulse, and no 
sounds. These views are erroneous, and have been ably refuted by 
M. Pigeaux, who has adopted opinions corroborative of those of Dr. 
William Stokes. 

Cause of the second sound. — Mr. Turner supposes the second 
sound to depend on the flapping of the pericardium on the heart. 
Dr. Williams considers it to be the effect of the flapping of the mitral 
and tricuspid valves against the walls of the heart. Mr. Spittal is 
rather inclined to attribute it to the rushing of blood into the ventri- 
cles, during their elastic dilatation. Mr. Spittal has erred, after ably 
and successfully refuting the theories of M. Laennec, Mr. Turner, 
and Drs. Barry and Williams. That he should not have formed a 
correct opinion as to the second of the consecutive sounds, is not to 
be wondered at, when we consider that he was misled with respect 
to the first. But it is with pleasure I seize this opportunity to ex- 
press the high sense I entertain of Mr. Spittal's talents and zeal in 
the cause of medical science, and his superior acuteness in ausculta- 
tion, of which I have several times availed myself in practice. Dr. 
W. Stokes performed some vivisections in August, 1829, to ascertain 
whether there is a want of synchronism between the impulse of the 
heart and pulse at the wrist, at the suggestion of Dr. M'Donnel, of 
Belfast, who had many reasons for doubting the correctness of Laen- 
nec's statements concerning the heart, wherein he describes the im- 
pulse felt at the side as the effect of the contraction of the ventricles. 
These experiments were performed in company with Mr. Hart, and 
in the presence of many pupils; the results were immediately made 
public by both these gentlemen, in their lectures and in private con- 
versation. They were well known in Dublin many months before 
the appearance of any other researches on the subject. In the course 
of these experiments, Dr. Stokes became convinced that the cause of 
the second sound is the motion of the blood during the contraction 
of the ventricles, and the dilatation of the auricles; for there appears 
to be no doubt that the dilatation of one set of cavities takes place 
at the same moment with the contraction of the other, a fact which 
was stated some time before by Dr. Barry. I entirely coincide with 
Dr. Stokes as to the second sound, and his researches will remove 
many of my doubts as to the possibility of determining disease of 
the valves and other parts on either side of the heart. If his opin- 
ion be correct, the sounds produced by disease affecting theauriculo- 



OF THE CIRCULATING SYSTEM. 453 

ventricular valves should be synchronous with the first sound, while 
those occasioned by disease of the aortic valves should be synchro- 
nous with the second. The subjects of Dr. Stokes's and Mr. Hart's 
vivisections were the rabbit and goat. These gentlemen arrived at 
the following conclusions: 

" 1st. The process of contraction begins at the auricular, and ter- 
minates at the ventricular portions of the heart. 

a 2d. The contraction of the auricle in the goat was evidently 
preceded by that of the sinuses of the vena cava. 

" 3d. The impulse at the side is produced by the dilatation of the 
ventricle. 

" 4th. After the expulsion of the contents of the ventricle, an in- 
terval of apparent rest occurs, during which, however, the auricles 
are filling." 

Having arrived at these conclusions, they next turned their atten- 
tion to the action of the arterial system. They found, 

" 1st. That in the state of health, the impulse of the heart pre- 
cedes the pulse at the wrist, by an appreciable interval. 

"2d. That this interval is more perceptible in proportion to the 
slowness of the heart's action. 

" 3d. That the length of the interval is directly as the distance of 
the vessel examined from the heart. 

" 4th. That hence the wave of blood at each pulse is progressive 
through the arterial system, and not an instantaneous impulse, as has 
been supposed." (Ed. Med. and Surg. Journal, October, 1830.) 

Certain remarkable sounds, which accompany the action of the 
heart and arteries, require a few observations in this place. 

1st. The blowing or bellows sound, (bruit de sottfflet,) as it is 
called by Laennec, from its resemblance to the sound produced by 
that instrument when blowing the fire. This sound, when present 
in the greatest degree, entirely masks the natural sounds produced 
by the action of the heart. It is sometimes heard in the subclavian 
and carotid arteries. 

2d. The sound of the saw or file (bruit de rdpe) is another phe- 
nomenon, occasionally presented by the action of (he heart. Both 
this and the blowing sound were formerly considered as invariably 
indicating disease of the valves of the heart; and although often 
present ill such circumstances, yet are by no means to be considered 
as pathognomonic, as they may exist in a slight degree without any 
organic lesion of the' valves. Laennec states, that the only disorder 
which appeared to him constantly, or almost so, to accompany the 
bellows and file sound, was a state of nervous agitation, which, how- 
ever, was more or less marked by other symptoms. These sounds 
are not unfrequently met with in young persons of a nervous tem- 
perament; and, id most cases, we can make ourselves pretty certain 
that Ibey ere owing merely to a nervous affection; for if we examine 
siH-h patient! in ■ Mate of repose, no particular sound will he heard; 
hut aftei violent exercise, or during a state of agitation, they become 
instantly perceptible: whereas, if they proceed from disease, they 
will never he entirely absent, although they may be increased by 
every cause which tends to hurry the circulation, and may be heard 



454 [GENERAL REMARKS ON DISEASES 

at all times in severe cases, even on the back. It appears probable, 
that even in the pure nervous affections, sounds, resembling those 
produced by disease of the valves, may hereafter be found to depend 
upon a congenital disproportion between the heart and the orifices 
through which the blood passes, and which produces the effect only 
when the circulation is hurried. 

Since writing the first edition, I have seen several dissections, 
which proved that both the bruit de sonfflet and the bruit de rdpe, 
but particularly the former, occasionally depended on hypertrophy, 
with dilatation of the cavities of the heart, as well as on disease of 
the valves. Examinations after death have convinced me, that both 
sounds may likewise be occasioned by disease of the aorta.* 

Dr. Scott, to whom I am indebted not only for the little knowledge 
I possess in the use of the stethoscope, but for much valuable assist- 
ance in writing this part of the work, informs me, that he has ob- 
served a very peculiar sound during the action of the heart in nervous 
persons;— it is a slight click or jingle, sometimes resembling the 
splashing of water in a metallic vessel. The first time he met with 
this sound, was in a very young woman, in a state of insensibility, 
where the sound gave the distinct idea of a fluid in the pericardium, 
agitated by the heart. I have noticed this remarkable phenomenon, 
also, but am more inclined to attribute it to small quantities of fluid 
and flatus moving from one part of the stomach or bowels to another. 

3d. The purring or whizzing vibration — the cat-purr, may also 
be briefly mentioned. It is a peculiar sensation communicated to 
the hand placed on the cardiac region, and which Corvisart consi- 
dered a sign of ossification of the valves, more particularly the mitral. 
This vibration is in general confined to the left side of the chest, and 
though it is no doubt met with in almost every case of considerable 
contraction of the valves, yet it is sometimes perceived in a slight 
degree when no organic lesion exists. 

[The great interest which has, of latter years, been excited in the 

* [M. Andral has recently instituted some experiments in relation to these sounds, 
which afford additional evidence that they often exist wholly independent of a dis- 
organization or alteration of structure, and that they are consequent to certain 
changes in the relative proportion of the elements of the'blood. He takes, as we shall 
hereafter see, the proportion of red globules in healthy blood, to be as 127 in 1000 
parts, and then states that the causes capable of producing the bruit de soufflet, or 
bellows sound, are the following: — 

First, when the globules have diminished sufficiently to be below the cipher 80, the 
bruit de soufflet exists in the arteries in a constant manner. I have never found a 
single exception lo this law. 

Second, when the globules have remained above the cipher of 80, the bruit de 
soufflet can again show itself, but it is no longer constant; we continue to hear it often 
enough when the cipher of the globules oscillates between 80 and 100; it is met with 
again, but much seldomer, according as the cipher of the globules passes 100, and 
finally, it is no longer observed when the cipher of the globules is raised above the 
physiological mean. 

Moreover, whatever is otherwise the nature of the disease in which these diminu- 
tions of the globules exist, the bruit de soufflet of the carotids does not show itself the 
less; I have proved its existence in the most different cases, putrid fevers, eruptive 
fevers, pneumonias, acute articular rheumatism, and in a great number of chronic 
diseases. But in all these cases it only took place with the ciphers of the globules 
marked above. 

The bruit de soufflet is often present in women with child, which is in relation with 
the frequent diminution which the globules undergo in them.— Andral.— Hcema- 
tologie Pathologique.] 



OF THE CIRCULATING SYSTEM.] 455 

medical profession, in relation to the action of the heart, is familiar 
to everyone; and the admirable epitome which has been given of the 
present state of the question, needs little, if any addition beyond the 
following results of a series of experiments performed by l)rs. Pen- 
nock and Moore of this city. Without attempting to analyze the 
memoir, published by these gentlemen, I shall merely place before 
the reader the conclusions to which they arrived, after a most ardu- 
ous and elaborate investigation : 

" \st. The impulse is synchronous with, and caused by, the ven- 
tricular contraction,— and when felt externally, arises from the strik- 
ing of the apex of the heart against the thorax. 

" 2d. The expulsion of the blood from the ventricles is effected by 
an approximation of the sides of the heart only, and not by a con- 
traction of the apex towards the base ; during the systole, the heart 
performs a spiral movement, and becomes elongated. 

" 3d. The ventricle contracts, and the auricle dilates at the same 
time, occupying about one-half of the whole time required for con- 
traction, diastole and repose. Immediately at the termination of the 
systole of the ventricle, its diastole succeeds, occupying about one- 
fourth of the whole time, synchronous with which the auricle dimi- 
nishes, by emptying a portion of its blood in the ventricle, unaccom- 
panied with muscular contraction. The remaining fourth is devoted 
to the repose of the ventricles, near the termination of which the 
auricle contracts actively, with a short, quick motion, thus distending 
the ventricles with an additional quantity of blood: this motion is 
propagated immediately to the ventricles, and their systole takes 
place, rendering their contractions almost continuous. 

" 4th. From the termination of their diastole to the commence- 
ment of their systole, the ventricles are in a state of perfect repose, 
their cavities remaining full, but not distended, while those of the 
auricles are partially so, during the whole time. 

" 5th. The sounds are produced by the motions of the heart or its 
contents, and not by striking against the thorax, as proved in all the 
experiments; being much louder when the stethoscope was applied 
directly to the heart than when to the chest, or with the lungs inter- 
posed. 

'• ')///. Tie: sounds are more distinct when the muscle is thin, and 
contracts qnickly. Hence the clear, flapping character of the first 
SOfrnd over the right ventricle, as compared with the left. 

"1th. The first sound, the impulse, and the ventricular systole,are 
synchronous. This sound may be a combination of that caused by 
the contraction of the auricles, the flapping of the auriculo-ventri- 
eular valves, the rush of blood from the ventricles, and the sound of 
muscular contraction. When the heart was removed from the body, 
tie- ventricles cut open and emptied of their contents, the auriculo- 
ventncular val . I, and a sound, resembling the first, still 

heard, ii may be chiefly attributed to the muscular contraction. That 
valves aid but slightly in its production, may also be inferred 
from experiment in. 

"8/A. The second sound is caused exclusively by the closure of 
the semilunar valves from the reaction of the arterial columns of 



456 [GENERAL REMARKS ON DISEASES 

blood upon them, in its tendency to regurgitate through the aortic 
and pulmonary orifices. This is proved by the greater intensity of 
this sound over the aorta than elsewhere, the blood having a strong 
tendency to return through the valvular opening ; by the greater 
feebleness of the sound over the pulmonary artery, which is short, 
and soon distributes its blood through the lungs, thus producing but 
slight impulse upon the valves in the attempt to regurgitate ; by the 
disappearance of the sound, when the heart becomes congested and 
contracts feebly ; and, finally, on account of its entire extinction 
when the valve of the aorta was elevated. 

" 9th. The second sound is synchronous with the diastole of the 
ventricle."*] 

Symptoms produced by diseases of the heart and large blood- 
vessels. — Before describing the different diseases of the heart, a 
brief enumeration may be given of the general symptoms which 
accompany these affections. In the early stages, it is of the utmost 
consequence to form an accurate diagnosis; but the general symp- 
toms are very nearly similar in all. These are, habitually short and 
difficult respiration ; palpitation, and a feeling of oppression about 
the heart on any sudden or violent exertion, as in running or walking 
up an ascent. The late Dr. Monro was so well aware of this, that 
before examining a patient suspected to labour under disease of the 
heart, he was in the habit of desiring him to ascend a flight of 
stairs quickly. Emotions of the mind frequently induce paroxysms 
of panting and dyspnoea. Sleep is often disturbed by sudden starl- 
ings and fearful dreams ; there is an anxious cast of countenance, 
and a marked degree of irritability of temper and restlessness ; deter- 
minations of blood to the head take place ; and very generally a 
disordered state of the digestive functions is observed, indicated by 
impaired appetite, flatulent distension, irregularity of the bowels, &c, 
which invariably aggravate the feeling of uneasiness about the heart. 
Sometimes the patient suffers most violent paroxysms of pain, which 
are occasionally attended with great vascular action and palpitation, 
at others with diminished vascular action, and a tendency to syncope. 

In the last stages, diseases of the heart can in general be recog- 
nized at a single glance ; the patient is unable to lie down; he there- 
fore requires to be propped up in a chair or bed ; the face is puffed ; 
the lips are swollen, and display the different shades of colour pro- 
duced by impeded circulation through the lungs; the legs and scrotum 
become cedematous, and dropsical effusions often take place into the 

[* Medical Examiner, No. 44. M. Cruveilhier has yet more recently published 
some observations on an infant born with its heart completely exposed, and protrud- 
ing through an aperture in the thorax. It lived twenty-four hours afier birth. He 
found only two conditions of the heart,— contraction and dilatation; that of repose 
generally mentioned by authors, was completely wanting. During their systole, the 
parietes of the ventricles became pale, and their surface rugged, and in folds. " The 
two sounds of the heart," says he, " have their seat at the origin of the pulmonary 
and aortic arteries, and their cause is the flapping {claquement) of the sigmoid valves. 
The first sound, which coincides with the ventricular systole, and with the dilatation 
of the arteries, is the result of the replacing {redressement) of the sigmoid valves, 
probably lowered. The second sound, which coincides with the ventricular systole, 
and with the contraction of the arteries, is the result of the lowering of the sigmoid 
valves, pushed down by the reflux of the retrograde blood."— Gazette Medicate, 
quoted in Braithwaite's Retrospect, Part 4.] 



OF THE CIRCULATING SYSTEM.] 457 

cavities of the thorax, pericardium, and abdomen. Haemorrhage 
from the lungs is not uncommon; and the case sometimes terminates 
in apoplexy: indeed, diseases of the heart frequently terminate in 
sudden death. The pulse varies much, according to the particular 
disorganization : in hypertrophy, for example, it is hard, full, and 
bounding; in dilatation, feeble, compressible, and irregular in point 
of strength; in valvular disease, small, and easily rendered intermit- 
ting by exertion, and by mental emotions. Some of these symptoms 
are, however, common to other diseases; and those of the earlier 
stages may depend on disorder of the digestive organs, or may ac- 
company affections usually termed nervous. It is of extreme con- 
sequence that these cases should be distinguished, if it were only to 
save the reputation of the medical attendant, as patients so affected 
generally die suddenly, at a time when the physician has given a 
favourable opinion, or, perhaps, lightly estimated the complaints of 
the patient. With the assistance of the stethoscope and percussion, 
combined with an accurate study of the individual characters of the 
case and the constitution of the patient, we shall be able to form a 
more correct diagnosis than those who trust solely to the ordinary 
means of investigation. 

In making our examinations with the stethoscope, we should be 
particularly careful that the patient is free from agitation, and has 
been in a state of perfect quietude for some time. 

Causes of diseases of the heart. — The causes of diseases of the 
heart are imperfectly known; affections of the lungs, which give rise 
to long-continued and severe dyspnoea, are, no doubt, among the 
most frequent causes ; they are considered by Laennec as the best 
ascertained. We know, perhaps, with more certainty, that diseases 
of the heart give rise to various affections of the lungs, more particu- 
larly haemoptysis, and pulmonary apoplexy. 

A disproportion between the diameter of the aorta and size of the 
heart, was considered, by Corvisart, as a constant cause of dilatation ; 
and it is probable that a congenital disproportion is a frequent cause 
of hypertrophy. 

Affections of the mind have been considered as the most usual 
diseases of the heart; thus, we are told, that during the 
French Revolution, these affections became much more common than 
at any previous period. The influence of depressing and exciting 
passions, in predisposing to disorders of this kind, can scarcely be 
Questioned; hut it must be borne in mind, that about the period 
above alluded to, greater attention began to be directed to this branch 
of pathology, and in point of fact, these diseases became belter un- 
derstood, and more frequently recognized. Every cause which dis- 
tUrbfl tin- balance of the circulation, producing an overload of blood 
about the heart and lungs, excites this class of affections; hence I 
have been sole to trace it to long-continued intermittent fevers. It 

would rippi.ir that rheumatism is a frequent cause of enlargement of 
the heart : it is well known, by practical men, that pericarditis Some- 
times comes on during an attack of acute rheumatism. We find that 
thOM who have sullen, 1 repeatedly from acute rheumatism, not 1111- 
frequeiltly fall victims to enlargement or other diseases of the heart. 
39 



458 [GENERAL REMARKS ON DISEASES 

In what relation these diseases stand to each other cannot at present 
be discussed. Gastric irritation is a very common source of disor- 
dered action of the heart, and, it is probable, often lays the founda- 
tion of structural disease in that organ. 

In conclusion, it may be confidently stated, that no subject con- 
nected with the exercise of the medical profession, deserves more 
attentive investigation, or presents more extensive views of deep 
practical interest and importance. 



[ON THE MORBID CONDITIONS OF THE BLOOD.] 

[Every practitioner is accustomed to notice certain familiar changes 
which the blood undergoes in various diseases; and, although obser- 
vations of this kind are as old as the oldest medical records, we have 
not, until lately, been made acquainted with the precise nature of 
these changes, and the pathological conditions on which they depend. 
Among the most laborious and successful inquirers into the varia- 
tions which the blood undergoes in diseases, is M. Andral, whose 
name is honourably blended with every department of pathological 
research. He has published the result of his observations in a volume 
which has just been very ably translated into the English language, 
by two gentlemen of this city;* and from this instructive volume I 
shall take the liberty of collecting and arranging the more important 
facts, and, especially, those that have a practical bearing. 

The first requisite, in this inquiry, is to bear in mind the relative 
proportions of the three grand constituents of the blood in its healthy 
state, — febrine, red globules, and serum. 

The average proportion of fibrine is found to be only three parts 
in a thousand; but M. Andral states that the quantity may, and does 
vary from 25 to 35 in the healthy state. 

The proportion of red globules is as 127 to 1000; the maximum 
may be stated at 140; the minimum at 110; but the former is asso- 
ciated with plethora, which, in the progress of development, becomes 
a strictly morbid condition. 

The mean of the solid materials of the serum, which are composed 
almost entirely of albumen, is SO in the 1000 parts of blood. 

One of the pathological conditions of the blood is a change in the 
relative proportion of its three parts. " The normal elements of the 
blood," observes M. Andral, " in which the present state of our 
knowledge enables us to trace these changes of proportion, are the 
globules, the fibrine, the albumen of the serum, the different or- 
ganic materials, other than the albumen, and which are found in the 
serum, (fatty matter and others,) then the inorganic principles con- 
tained in the blood, and, in particular, the free alkali, its different 
salts, and its water, "t 

[* Pathological Hematology.— An Essay on the Blood in Disease. By G. Andral. 
Translated from the French, by J. F. Meigs, and Alfred Stille. M. D. Philadelphia, 
1844-] 

[t Page 37.] 



OF THE CIRCULATING SYSTEM.] 459 

Again, independently of this change of proportions, the principles 
of the blood may become modified in relation to their size and phy- 
sical properties. 

Lastly, new principles are sometimes developed in the blood, 
which, though foreign to its healthy condition, have their analogies 
in other parts of the organization ; such are pus, milk, &c, which. 
are sometimes found in the blood. With these few preliminary re- 
marks, we proceed to inquire into the condition of the blood in dif- 
ferent diseases, without attempting to introduce those numerical 
statements and experimental operations, which give so much value 
Id M. Andral's researches, and for which the reader is necessarily 
referred to the work itself. 



OF THE BLOOD IN PLETHORA. 

The proportion of fibrine is not appreciably increased in plethora, 
nor is there any remarkable change in the organic materials of the 
serum ; but the peculiar character of plethora is derived from the 
augmented proportion of the globules of the blood, and the much 
smaller quantity of water that it contains; whence its high colour, 
the large and moderately firm clot, and the absence of the buffy 
coat ; or rather the latter depends upon the small proportion of fibrine 
relatively to the globules. This condition modifies the healthy action 
of the organs ; all the functions are more active; digestion is rapid; 
respiration is favoured by the great development of the cavity of the 
thorax; the heart beats forcibly, and the circulation is rapid. 

Plethoric individuals arc subject, as every one knows, to certain 
symptoms, as vertigo, tinnitus annum; preternatural heat in the head, 
&c, which M. Andral explains to arise not from congestion of blood 
in the brain, but from the passage of an excessive quantity of the 
globules of the blood through the vessels of that organ. 



OP THE IJLOOI) IN ANAEMIA. 

Tin: fundamental character of anaemia is a diminution, in various 

obular element of the blood; for the fibrine arid 

solid matter of the serum present their natural proportions. This 

remark holds good both in respect to spontaneous anncmia, and that 

winch results from haemorrhages; so, also, in pregnant women who 

become ansamic, the globules alone diminish. Again, men ire some- 

ittacked with spontaneous anemia, which presents all the cha- 

•I the chlorosis of women, but the blood assumes the same 

proportions we have already mentioned. It is a curious fact, that 

• of blood is not nnfrequently seen buffed in chlorotic patients 

and in per onsol both exes who arc subject to anaemia; whence M. 

Andral and others h ave inferred that the bully coat is not always 

an evidence of the presence of inflammation. 

When the blood i - deprived of a certain proportion of its globules, 
the patient suffers with extreme prostration, various nervous symp- 



460 [GENERAL REMARKS ON DISEASES 

toms, and impaired digestion, respiration, and circulation. More- 
over, it is not uncommon to meet with persons of a florid complexion 
and seemingly plethoric habit, who have, nevertheless, a deficiency 
of red globules. 

" Observe, in effect, such individuals a little more closely, and you 
will be struck with their feebleness; they will have, as in the most 
advanced anaemia, vertigo, dyspnoea, and palpitations upon the slight- 
est effort; they will bear with difficulty any kind of exertion, and 
still worse venesection, which, far from diminishing, will increase 
their symptoms."* 

We must not, then, forget, adds the author, that at the commence- 
ment of every disease, the blood may present two great modifications 
in its globules, one of which belongs to plethora, the other to anaemia. 
It is upon a variation of increase or diminution in the cipher of the 
globules that depend the peculiar symptoms then observed, and which 
are superadded to those of the disease. 



OF THE BLOOD IN FEVERS. 

In the entire class of pyrexia, the fibrine never augments in quan- 
tity, provided they are not complicated with strictly inflammatory 
affections ; and, in fact, it sometimes diminishes to a point unknown 
in any other acute disease. It is not even augmented by the pre- 
sence of the variolous eruption, nor by the dothinenteritis of typhoid 
fever. 

There are some fevers which naturally tend towards a favourable 
termination; while there are others which, from their very com- 
mencement, are attended by symptoms indicative of extreme irregu- 
larity of the entire organism, and which threaten dissolution itself; 
under these circumstances, the blood has been observed to present a 
peculiar appearance, verging to decomposition; whence the terms 
putrid, adynamic and typhoid fever. The true typhoid fever is thus 
characterized more or less from its commencement, and in its severer 
forms is a proverbial illustration of this pathological state. This 
alteration of the blood consists of a diminution of the fibrine ; and 
is therefore the reverse of what takes place in the phlegmasiae. The 
blood, when drawn, presents the following appearances: the serum 
and the clot are imperfectly separated from each other, whence it 
happens that there seems to be but little serum in proportion to the 
clot. The latter is voluminous, often filling the whole breadth of 
the containing vessel. "Its consistence is always slight; it is torn 
and broken with the greatest facility; and there are some cases 
where even by the slightest pressure, it may be reduced to a true 
condition of diffluence ; it ceases then to form a single mass, and is 
divided into a number of grumous portions, which mix with the 
serum and colour it of a more or less deep red."t The network* 
that kept the globules together and which, by its power of contrac- 
tion, squeezed out the serum, remains only in an imperfect state; 

[* Page 49.] [t Page 54, 55.] 



OF THE CIRCULATING SYSTEM.] 461 

whence also the great size of the clot, which is found to be in an in- 
verse proportion to its density. It is manifest, moreover, that the 
size of the clot is in part due to the larger proportion of globules it 
contains, for these, in place of diminishing like the fibrine, are some- 
times become remarkably increased in quantity. Another peculiar- 
ity of the blood, in idiopathic fevers, is the absence of the buffy coat; 
and M. Andral avers that he has never met with this appearance 
in inflammatory fever, in typhoid fever, whether of a mild or a 
severe form, in measles, scarlatina or in small-pox, unless there was 
some phlegmasia! complication. In fact, the specific cause of pure 
pyrexial diseases "acts on the blood in such a way that it tends to 
destroy its spontaneously coagulable matter, while the cause which 
produces the phlegmasia tends, on the contrary, to create in that 
fluid a fresh proportion of that matter." Finally, in reference to the 
pyrexiae, we shall merely observe the curious fact that the diminu- 
tion of the red globules does not lower the temperature of the human 
body; which is also true in those cases wherein the blood loses a 
portion of its fibrine. So far is the temperature from falling under 
these circumstances, that it may experience an augmentation of 
several decrees. 



THE BLOOD IN INFLAMMATION. 

In the true phlegmasia, observes M. Andral, there is an excess 
of fibrine relatively to the globules, which is the reverse of what 
takes place in typhus. The clot is smaller, dense, and of greater 
consistence, and, if properly drawn, presents a buffy coat of variable 
thickness ; a character which uniformly, except only in cases of anae- 
mia, is indicative of the presence of inflammation; for, while, in 
the phlegmasia;, the proportion of globules is unaltered, the fibrine 
becomes redundant, and the buffy coat reaches its full develop- 
Tlns phenomenon will result in every inflammation which 
is attended by fever, and notwithstanding the constitution may 
have been exhausted by chronic disease, or a more or less complete 
Mad: of anemia lias been established, the fibrine will, nevertheless, be 
augmented under the influence of whatever inflammation nun/ 
tUpervene; and 1 1 1 is result follows whether the subjects of acute in- 
Ihiniintion are stroin. r Of feeble, of B .sanguine or of a lymphatic 
temperament." The fibrine will thus increase to a point between <; 
the LOOO parts of blood; it will less frequently augment to 
Band 9, and in ran- instances has reached L 04, which M. Andral 
as the maximum; while the minimum is a point between 
•i and r>. 

Kvii ih" stomatitis, which follows the free use of mercury, presents 

ption to the preceding law. If any part of the mucous mem* 

■ i the digestive apparatus, from the fauces to the end of the 

attacked with a sufficient degree ef inflammation to excite to 

fever, the fibrine if ln< rea led to 5, 6 and 7, but never higher; while 

[• Page 66.] 



462 [GENERAL REMARKS ON DISEASES 

we have already adverted to the highly interesting fact, that this 
increase does not occur when the inflammation, seated in the follicles, 
exists only as one of the elements of a general disease, — typhoid 
fever.* 



THE BLOOD IN HEMORRHAGE. 

Every haemorrhage diminishes the proportion of globules in the 
blood, but unless very prolonged or copious, it has no appreciable 
influence on the fibrine; in other words, the blood does not differ 
from that observed in the pyrexias, and never presents the buffy coat 
unless' attended by some local inflammation. 



THE BLOOD IN DROPSIES. 

In simple dropsy the unvarying rule is that the effused serosity, 
even while it retains the same materials as the serum of the blood, 
contains a greater proportion of water, and much less of the organic 
principles, and especially of albumen. Thus in sixteen cases report- 
ed by M. Andral, he found the maximum of albumen to be 48, the 
minimum 4 ; so that this principle of the blood in no instance equaled 
the proportion that belongs to true serum. When the effusion of se- 
rosity has been excited by an inflammatory process, as in the drawing 
of a blister, the proportion of albumen is greatly increased. On the 
other hand the fluid, which is sometimes effused in hydatids of the 
liver, is as limpid as pure water, and shows no trace of albumen, 
even by the most delicate tests. 



THE BLOOD IN ORGANIC DISEASES. 

The mere secretion of tubercles, cancer and encephaloid matter, and 
the development of hydatids, do not augment the fibrine. So long as 
tubercle and cancer are unconnected with inflammation, the fibrine 
remains unaltered. " But as the softening of these hard masses ad- 
vances, and a process of elimination analogous to inflammation is set 
up around them, the blood becomes more and more charged with 
fibrine ; so that the excessive formation of this principle is not due 
to the development of the accidental production, but wholly to the 
inflammation excited by the latter at certain stages of its existence. 
This is a new proof to be added to the many others which show that 
the process engendering the different accidental productions, such as 
tubercle, cancer, melanosis, hydatid, &c, is not of an inflammatory 
nature."t 

The blood in incipient phthisis always presents a diminution of 
red globules, varying from 122 as the maximum, to 99 as the mini- 
mum; so that such persons are in a state of commencing anaemia, 

[* Page 71.] [+ Page 119.] 



OF THE CIRCULATING SYSTEM.] 463 

their blood having the character which results from repeated bleed- 
ings. In the advanced stages of phthisis the globules become less and 
less in proportion, until they frequently fall as low as SO; and M. 
Andral mentions a solitary example at 72. Is it not strange, he in- 
quires, that in chlorosis, without any appreciable alterations of the 
lungs, or other solid, the globules should even fall lower than 30, 
while their minimum is at 72 in a disease which it should seem that 
the state of the lungs could hardly permit the formation of the blood 
at all ? And yet not only do the globules not diminish as much as 
might be expected, but, when even a large part of the lung is de- 
stroyed, the fibrine increases, and the temperature of the body may 
rise, just as in typhoid fever, or acute pneumonia."* 



OF THE BLOOD IN THE NEUROSES. 

Clinical observation has long since demonstrated that one of the 
most frequent causes of nervous diseases is a certain feebleness of 
constitution; whence the scantiness of the globules in these affections. 
"Now it is well known that the increase or decrease of the globules 
of the blood indicates the vigour or feebleness of the constitution. If 
the globules be diminished, either by depletion or by insufficient 
nourishment, the nervous disorder will certainly be aggravated; but 
if the opposite course be pursued, in all probability the nervous af- 
fection will be mitigated. In this way may be explained the happy 
influence which the ferruginous preparations and substantial and 
nutritious food exert upon the termination of certain neuroses: and it 
is because the globules are inevitably diminished by depletion and 
diet, that we so often see such disturbance of the nervous functions 
follow great loss of blood, and a too prolonged abstinence from 
food."t 

In conclusion, I may repeat, that this abstract, while it may serve 
to show the practical importance of the work of M. Andral, should 
not be allowed to supersede the work itself, which is worthy of the 
careful perusal and study of every member of the medical profession.] 

[• Page 198.] [t Page 129] 



CHAPTER II. 
PALPITATION, AND ANGINA PECTORIS. 



PALPITATION. 



By this term I mean the occurrence of an unusually strong and 
frequent pulsation of the heart, without any organic lesion ; the pal- 
pitations produced by disease of the heart itself are to be considered 
afterwards.* The affection now under consideration is to be regard- 
ed as purely nervous, occasioned by excessive indulgence in various 
passions, by mental emotions, and very frequently, by a disordered 
state of the stomach and bowels. Stimulants of all kinds, violent 
exercise, excessive depletion, occasionally produce it. Palpitation is 
more readily excited in persons of a nervous and sanguine tempera- 
ment ; when first observed, the affection is generally slight and tran- 
sient, but by frequent repetition, the organ at last becomes so irritable 
that the least circumstance reproduces it. 

Nervous palpitations are frequently very distressing, even when 
the body is in a. perfect state of repose ; particularly during the first 
part of the night, and often prevent sleep for many hours. The ac- 
tion of the heart is not only accelerated, but increased in impulse and 
sound; sometimes the action is tumultuous, and occasionally so 
strong, that the person affected feels it painfully. There is some- 
times a sensation of internal agitation, particularly in the head and 
abdomen, and, as happens in hysteria, the urine is copious and lim- 
pid. 

[The pulse is extremely irregular, and often intermittent. In the 
language of Dr. Abercrombie, there is a series of quick, weak, flut- 
tering, irregular beats, with slight anxiety, acceleration of respira- 
tion, and a grieving sensation in the epigastrium, all which may con- 
tinue from a few minutes to an hour, or several hours, recurring at 
long intervals, or they may be of constant repetition throughout the 
day. A yet greater degree of the affection amounts to a fit of palpi- 
tation, consisting in increased impulse, sound and frequency of the 
beats, sometimes with irregularity, and generally with more or less 

[* Mr. Teale calls this affection Neuralgia of the Heart ; but adds, that he uses the 
term neuralgia in an extended signification, so as to embrace not only those condi- 
tions which are accompanied with pain, but various other morbid stales of the func- 
tions of nerves. — On Neuralgic Diseases, <^c, p. 42.] . 



[PALPITATION.] 465 

anxiety and dyspnoea ; there may also be pain in. the region of the 
heart, with constriction of the chest, and flatulent eructations.] 

Nervous palpitations are not to be neglected, as by frequent repe- 
tition they may lead to disease of structure, either in the heart itself, 
or in some other organ. Laennec says, that he has never seen any 
proof of the accuracy of this opinion, but I think I have. 

According to Laennec, in nervous palpitation, the first impression 
conveyed by the stethoscope is, that the heart is not enlarged. The 
sound, though clear, is not heard loudly over a great extent, but this 
very much depends upon the thickness of the parietes of the chest. 
In thin people, I hear the sound during palpitation, in every spot on 
the anterior part of the chest; and when the heart is acting very vio- 
lently, I have perceived it in the back also. With respect to the im- 
pulse, Laennec states, that in the nervous affection, the head of the 
observer is never sensibly elevated. This, he says, is the most im- 
portant and certain of any sign, when taken in conjunction with the 
frequency of the pulsations, which are always quicker than natural, 
most frequently from 84 to 96 in the minute. I have seen and felt 
the impulse of the heart in nervous palpitation, not only elevate the 
head of the observer, but raise the bed-clothes. Dr. Ferriar, one of 
the most accurate of observers, in detailing a case of violent palpita- 
tion of the heart, states, (p. 205, vol. 1st,) "Every stroke of the pul- 
sation raised her clothes, so as to be visible at some distance ;" under 
the use of castor, with attention to her clothing and diet, she reco- 
vered " in the course of a few weeks." In this affection, there are 
rarely any signs of determination of blood to the head or chest. 

It is rare that palpitations, produced by functional derangement of 
the heart, continue long at any time: they are in general transient, 
and are perhaps less troublesome when the patient is taking exercise 
in the open air than at other times. When of long continuance, and 
without intermission, they will, for the most part, be found to depend 
on some organic lesion. 

I have paid great attention, for the past few years, to what are 
called nervous palpitations, and have been astonished at their extreme 
frequency. I have made it a rule to interrogate every patient on this 
inbject, and am satisfied that at least one fourth of the whole num- 
llffen with irregular action of the heart. It is even common in 
infancy; and although the patient may be too young to describe his 
feelings, the intermittent pulse detects the irregularity of the heart's 
action. It is more frequent, however, in latter life, in women than 
in men, in the old than in the young, in those of a relaxed and irri- 
table habit than in the robust. It is familiar to dyspeptic persons, in 
whom I have known it to he very harassing when the stomach was 
empty, for example, just before dinner: under such circumstances, 
moderate eating relieves the palpitation; but if the patient continues 
to eal to repletion, or indulges in stimulants, so as to render diges- 
tion laborious, the palpitation not only returns but is greatly aggra- 
vated. 

Mr. Teals referethifl disease to a morbid state of the cervical gan- 
glia of the sympathetic nerve, He also remarks* and I think with 
great truth, that " palpitations purely nervous are principally distin- 



466 [PALPITATION.] 

guished from palpitations dependent upon organic disease of the 
heart, by the absence of other symptoms which denote a change of 
structure in that organ. In hypertrophy the pulsations of the heart 
are more vehement and more uniform : in dilatation they are felt 
over an unnatural extent of the chest ; when there is obstruction to 
the circulation from contracted orifices, from loss of function in the 
valves, or from morbid alterations of the muscular structure, there 
are generally, in a greater or less degree, blueness, oedema, &c."* 

Dr. Hope has pointed out several varieties of inorganic palpita- 
tion, which are the more important, because the treatment is differ- 
ent, and even opposite. 

1. Palpitation dependent on dyspepsia, hypochondriasis, hysteria, 
latent gout, mental perturbations of all kinds, and depressing ex- 
cesses, constitutes the first variety, and embraces a very large class. 
This affection may be readily distinguished from that which occurs 
in disease of the heart, by the occasional nature of the palpitation ; 
by its being relieved, instead of excited, by active exertion ; its ap- 
pearance while the patient is at rest; by a fluttering sensation in the 
epigastrium ; by the general prevalence of nervous symptoms, which 
aggravate the palpitation; by the regularity of the pulse in the in- 
terval between the paroxysms; and by the absence of valvular and 
aortic murmurs, and of undue impulse. 

2. Palpitation from a)ias?nia,—a. term which is now adopted for a 
peculiar condition of both sexes, but which was formerly restricted 
to the female constitution, under the name of chlorosis. This part 
of the inquiry we shall postpone for consideration in a future part 
of the work. 

3. Palpitation from too stimulant diet. Dr. Hope has particularly 
remarked this condition in young men who abandon active exercise 
in the country, where they have indulged a full diet, and come to 
reside in large cities, and to follow sedentary pursuits, without 
adapting their diet to the change in their habits. A febrile excite- 
ment takes place, with an accelerated pulse, whitish tongue, consti- 
pation, flushed face, with throbbing in the head, and sometimes of 
the whole body. Palpitation is induced on slight exertion, mental 
emotions, &c. This is, perhaps, the most manageable of the several 
forms of this malady. 

4. Palpitation from plethora. This condition is closely analogous 
to the one just described. It occurs in persons of a plethoric habit, 
who continue to live full, without the use of active exercise. In 
fact, the symptoms proceed from an engorged condition of the heart 
and whole vascular system. 

Treatment. — If we have careful reference to the several varieties 
of this affection, we shall find it necessary to vary the treatment 
according to the characters of each. When it arises from too stimu- 
lant a diet, or from any other irregularity of living, the treatment is 
too obvious to require further explanation than is contained in the 
chapter on dyspepsia. So, also, when it occurs in persons of a full 
habit.] 

[* Treatise on Neuralgic Diseases, p. 44.] 



ANGINA PECTORIS. 467 

Venesection, or the application of leeches, is sometimes advisa- 
ble, particularly in young plethoric individuals, who are affected at 
the same time with some febrile movement. French practitioners 
recommend the application of leeches to the anus in nervous palpi- 
tations. Laxatives, cold or warm bathing, moderate exercise in the 
open air, light nourishing diet, early hours, and avoiding the excit- 
ing cause, will usually be found successful, especially in those cases 
which present a divided nervous or anaemic character. When the 
affection, however, resists these remedies, various antispasmodics 
have been recommended, as opium, ether, musk, castor, and vale- 
rian; of all these, perhaps the best is the volatile tincture of valerian. 

[I have somewhere seen it asserted that twelve grains of camphor, 
given in divided doses through the day, will quiet the most tumul- 
tuous inorganic action of the heart. 

When palpitation can be traced to spinal irritation, Mr. Teale's 
plan of applying the remedies to the spine itself should not be omit- 
ted. It must, however, be acknowledged, that although leeching, 
cupping and blistering to the spine will sometimes relieve, and even 
remove the palpitations for a time, yet they are very liable to recur ; 
and most persons seem rather disposed to bear them than to submit 
to the frequent repetition or long continuance of active counter-irri- 
tation. I am convinced that long travel, and active occupation of 
body and mind, avoiding, of course, excessive fatigue and over-ex- 
citement, are the most certain means of counteracting nervous pal- 
pitations. In one instance considerable relief was obtained by wear- 
ing a broad belt, so as to compress and support the lower part of the 
abdomen.] 



ANGINA PECTORIS. — NEURALGIA OP THE HEART. 

This dreadful disease generally makes its attack in the following 
manner : It is commonly first felt when an individual is walking up 
hill ; he is suddenly and unexpectedly seized with an agonizing sen- 
sation in Ins breast, a little to the left of the sternum; he experiences 
a sense of constriction and suffocation, which obliges him to stop. 
After a little rest, these symptoms disappear, and he flatters himself 
that it is nothing more than a common stitch in the side, from walk- 
ing too quickly. I have known a person fall down in a state of 
temporary asphyxia, even in the first attack ; those affected in this 
manner fancy that they have merely fainted from excessive pain. 
ial such attacks may take place in the course of a i'ew years, or 
even a few months, the paroxysms continuing only for one or two 
minutes, and the person thinks nothing further of them. In the 
course of time, however, tiny return more frequently ; the pain be- 
comes more and more excruciating, and the paroxysms continue 
longer. In the early part of the disease, exercise seems to be re- 
quired to bring on a paroxysm, hut wlim more advanced, every little 

excitement or exertion of mind or body, or eating an indigestible 

Bltide Of food, produces an attack ; at last, the paroxysm comes on 
without any assignable cause, even when in bed, and during sleep. 



468 ANGINA PECTORIS. 

At the first onset of the disease, the pain is usually confined to the 
breast, in the region of the heart; afterwards it extends towards the 
shoulders, and frequently affects the superior extremities down to 
the wrists. I had a gentleman under my care, who complained of 
the pain extending from the breast to the arms, stopping exactly at 
the insertion of the deltoid muscle on each side. In severe cases, 
the patient is pale, perhaps quite ghastly — his features contracted — 
his eyes hollow — his countenance expressive of the most dreadful 
suffering ; — his body perhaps cold, and covered with a cold clammy 
sweat; — his respiration is quick, but free; that is to say, the patient 
can, if you desire him, occasionally take in a deep inspiration. In 
such cases, the pulse is in general slow, and so contracted and weak 
as scarcely to be perceptible; but this varies much, for in other in- 
stances, particularly when the skin is warm, and the face flushed, 
the pulse is quick, strong and irregular. I have seen cases in which 
it was perfectly natural in strength and number of pulsations during 
a paroxysm. 

In slight cases, the whole paroxysm is sometimes over in half an 
hour; in others, in an hour; and it ceases often with a discharge of 
flatus from the stomach and bowels. Sometimes it disappears sud- 
denly leaving no sense of uneasiness behind; at others, considerable 
soreness remains in the chest for several hours or days. 

In the most dreadful cases, the patient never feels entirely free 
from uneasiness and constriction in the chest, and he dreads making 
the least exertion. 

In the year 1826, I was requested, by one of my pupils, to see a 
gentleman who had had several attacks of this disease, and was then 
labouring under one of the most severe paroxysms I have ever wit- 
nessed, which had continued for several days before my visit. It 
was most afflicting to see a strong and a brave man weeping like a 
child, and imploring relief in the most impassioned strain. 

An interesting case of angina pectoris occurred in my dispensary 
practice in the year 1S28. The patient was carefully attended by 
the late Dr. T. Briggs,* formerly of Liverpool, from whose notes the 
following particulars are taken : — James Terry, aet. 38, a remarkably 
tall and athletic man, by trade a sawyer, habits temperate. Has 
been ill three years; his complaints began with occasional fits of 
palpitation, and severe pain in the region of the heart ; but he was 
able to continue at his work for the first three months. He was then 
obliged to relinquish his occupation from the frequency and violence 
of the paroxysms, which were most severe when walking, or making 
any unusual exertion. He found relief by pressing a walking stick 
strongly against the breast during the fit. His symptoms have be- 
come progressively worse : he has been under the care of many medi- 
cal gentlemen, and has been put under the influence of almost every 

* Dr. Briggs' benevolent and enterprising spirit led him to join the late expedition 
to Africa, where he fell a victim to disease ; and I regret to learn, that an effort has 
been made to tarnish his reputation by some one connected with the enterprise, by 
way of accounting for its failure. But it has not produced the desired effect. His 
aged parents may rest assured, that notwithstanding the wicked attempt to throw 
odium upon their son, his memory will be long cherished by all who had the pleas- 
ure of knowing him. 



ANGINA PECTORIS. 469 

known remedy. Mr. Liston ordered him to be bled twice, and blis- 
tered many times, without relief. In the infirmary of Edinburgh, 
under Dr. Alison's care, he was bled again, and took mercurial medi- 
cine till the mouth was made sore, with temporary benefit. But in 
a fortnight he became as bad as ever he had been, and Dr. Alison 
advised him to go to the country. In continuing the history of the 
case, he stated that a gentleman punctured "the bag of his heart," 
and blew air into it; "but I understand" says Dr. Briggs, '-that 
the air was injected from a bladder into the cavity of the left p ( 'e li- 
ra, and teas taken out next day." 

Terry is now (13th Nov. 1S2S) seldom free from violent pain in 
the chest, which he compares to that produced by boiling water ap- 
plied to the body. The pain shoots down the arms to the wrists ; it 
is always brought on by any muscular exertion, during the act of 
eating or drinking, and voiding stools or urine, and by lying down 
in a recumbent posture. He is always worse during the night. The 
violence and extent of the pain can be diminished by taking a deep 
inspiration, and keeping the lungs distended, and by pressing the 
chest with considerable force against the back of a heavy old-fash- 
ioned arm chair which he keeps for the purpose, and in this posi- 
tion he generally spends the night. The inferior extremities are 
oedematous, and greatly enlarged. Appetite good ; but he eats very 
little, and that slowly, in consequence of the exacerbation of pain 
during the act of swallowing. Digestion appears to be perfect, and 
tli': state of the bowels regular. The heart's impulse is very great 
— it shakes the whole frame, and when the patient leans over the 
chair, the pulsations may be counted by the violent motion of the 
heart against the posterior part of the thorax. Over every part of 
the thorax there is a sound like the rushing of water, corresponding 
to the contractions of the heart. This sound masks all other sounds, 
even that of respiration; and a similar sound is perceived by apply- 
ing the ear over any considerable artery. The pulse is strong and 
full — it vibrates against the linger, imparting a sensation as if the 
ATtflry were ready to burst. The pulse, which is sometimes stronger 
in 006 arm than the other, generally beats (JO in a minute — now and 
then there is a double beat, as if an additional pulsation were inter- 
I; during B paroxysm the pulse is suddenly quickened so as to 
beat 120. 

Al thif period the patient's sufferings were occasionally mitigated 
by large doses of the wineof colchjcum, and tincture of byoscyamus ; 
but he soon gave up these remedies, from the: languor and drowsi- 
Ihey occasioned. Death took place early in the morning of 
the 9th December, having complained for some tunc previously of 
• pain in the right thigh and knee, which were intensely swol- 
len from effusion in the cellular substance. Before bis death, he 
talked calmly of the event winch was to terminate the most severe 
bodily suffering 1 have ever had the misfortune to witness; and he 
desired his wife to allow me to take away any part of his body that 
mi-lit I,.: found diseased on dissection. 

lamination of the body took place on the following day, 
10th December, 30 hours after death. 
40 



470 ANGINA PECTORIS 

Putrefaction had already made great progress; the cuticle was 
everywhere loose, and the body crepitous from air in the subcu- 
taneous cellular tissue. The lower extremities and scrotum were 
tense from oedema. The thorax capacious and well formed, only it 
was deeply indented by the constant pressure on the chair. 

On opening the thorax, the pericardium, containing a heart of 
enormous size, seemed to fill the chest, and concealed the other con- 
tents. It lay obliquely across, occupying a space of about fourteen 
inches, extending from the 7th left rib to the 1st on the opposite side. 
In size it resembled a large ox's bladder fully distended. The right 
lung, compressed into a narrow space, adhered firmly to the sur- 
rounding panetes everywhere, except in the antero-superior part. 
It was greatly engorged with blood, but upon minute examination, 
was found healthy in structure. The left lung, free from adhesions, 
was found compressed into a small space also. The heart was then 
carefully removed, when the fore part of the bodies of five or six of 
the dorsal vertebrae were observed to be partially absorbed by the 
pressure of the heart. On opening the pericardium, it was found to 
contain a small quantity of serous fluid, and some bubbles of air ; its 
coats presented a natural appearance, and there were no adhesions 
with the heart. The heart appeared to all present to be about the 
size of that of an ox — it was enlarged in every part, and the left 
auricle and ventricle were fully distended with blood. Both auricles 
and ventricles were in a state of hypertrophy, and greatly dilated; 
the left ventricle contained more than twelve ounces of blood. The 
orifices were all remarkably dilated also, but the valvular apparatus 
was found in a sound state. The size of the aorta was not much, if 
at all, increased from the arch; its internal surface was vividly red, 
as were the mucous membranes in every situation. The heart and 
pericardium, forming two dried preparations, are preserved in my 
museum. 

Angina pectoris rarely attacks people under forty ; gouty subjects, 
and those who are corpulent, seem to be more liable to it than others. 
It appears to attack men more than women ; and I believe that 
sedentary habits create a predisposition to it, as well as long-con- 
tinued and very violent bodily exertion. 

•Appearances on dissect ion, and pathological remarks. — This dis- 
ease has attracted considerable attention on the part of pathologists 
to ascertain its nature and seat, since it was first noticed by Dr. 
Heberden, in 1768, in a paper contained in the 2d vol. of the " Trans- 
actions of the College of Physicians" of London. 

Subsequent writers have committed a great error by attributing 
angina pectoris to one particular disorganization : thus, one has attri- 
buted it to ossification of the cartilaginous extremities of the ribs, a 
second, to ossification of the valves of the heart; a third, to fat accu- 
mulated about the heart; a fourth to dilatation and hypertrophy of 
the heart. Dr. Parry supposed that it depended on ossification of 
the coronary arteries;— Dr. Haygarth, on inflammation of the medi- 
astinum; — Dr. Hooper, on diseases of the pericardium;— and there 
are many who think it is produced by asthma. Dr. Hosack, an 
American physician, is of opinion that it most frequently arises from 



ANGINA PECTORIS. 471 

general plethora, more particularly "from a disproportionate accu- 
mulation of blood in the heart and large vessels." I have seen each 
of these morbid appearances on dissection, in subjects who were 
never affected with angina pectoris; and it has been alleged, that 
patients have died suddenly from this affection, in whose bodies not 
the slightest trace of disease of any kind was perceptible, which has 
led some to assert that it depends upon scrofula, syphilis, a nervous 
temperament, or a peculiar affection of the par vagitm. Dr. Parry's 
opinion seems still to have great weight with many in the profession; 
but it may be mentioned, that I have seen two cases in which the 
coronary arteries were extensively ossified, and a third, in which 
they were completely so, and yet none of the patients had symptoms 
of this disease. A remarkable case of the same kind, which hap- 
pened many years ago, is detailed in the 1st vol. of the "Medical 
Communications," by Mr. Watson. In justice, however, to the 
memory of Dr. Parry, it ought to be stated, that he did not attribute 
the disease to the effects of ossification of the coronary arteries alone, 
for he distinctly states, that the symptoms show that an accumulation 
of blood takes place about the heart and large vessels. This state- 
ment goes so far to confirm the opinion of Dr. Hosack, which Dr. 
Forbes assures us is more in accordance with his own observation 
than any of the other opinions; but he adds, that " in persons sub- 
ject to this complaint, in whom no severe organic disease of the 
heart existed, I have generally found, by auscultation, that the organ 
was possessed of thin parietes and feeble powers."* In my work 
on " Puerperal Fever," which was published in the year 1822, a case 
of angina pectoris is recorded, which was evidently produced by an 
accumulation of blood in the heart and large vessels. The life of the 
individual appears to have been saved by timely blood-letting; thir- 
teen years have now elapsed, and there has been no tendency to a 
return of the disease. 

ina pectoris is now regarded, in accordance with the views of 

nec, as a neuralgi 1 of the nerves of the heart, mostly connected 
with -Mm': organic lesion of that organ, and'certainly always aggra- 

I by mk-Ii lesions I>ut here again pathologists differ as to the 
nerves involved in the affection, Desportes referring it to the pneumo- 

1 nerve, and Laennec to the filaments which the heart derives 
from tin: sympathetic. M. Bouillaud thinks the pain is seated in the 
phrenic and intercostal nerves. There is no reason why it may not 
be sometimes in one of these nerves, sometimes in all ; and be propa- 

1 to others, as Dr. Hope remarks, by sympathy or anastomosis, 
viz: "to the superficial cervical plexus and its anterior thoracic 
branches, Whence proceeds the pain in the neck, and on the surface 
of the chest; to the branches of the brachial plexus, especially the 
Dinar, whence arises the pain descending to the elbow, and some- 
times io the fingers ; finally to the branches of the lumbar and sacral 
eus, whence tin 1 pun and numbness fell in the tlnuhs .and legs, and 
even in ihe spermatic cord ami testicles. "t] 

Treatment. — The symptoms of angina pectoris occasionally ac- 

• T ec. i' 899. 

[t Hope. Dl '•.'-•• of the Beart, )> 46&] 



472 ANGINA PECTORIS. 

company such a variety of organic lesions, and take place from what, 
to all appearance, may be considered a neuralgic affection, that it is 
scarcely to be wondered at that so many remedies have been re- 
commended, and so few found serviceable. 

If there be marks of general plethora, with or without an organic 
affection of the heart, blood is to be taken from a vein, particularly 
if there be signs of an accumulation of blood either in the heart or 
lungs; at the same time, we must be careful to restore the heat of the 
body, if it be below the natural standard. I have so frequently seen 
a neglected state of the stomach and bowels precede an attack of an- 
gina pectoris, that I consider it of the greatest importance to clear out 
the prima? viae as speedily as possible. Should the attack come on 
soon after a meal, an emetic is to be prescribed; if not, purgatives 
are to be had recourse to, and repeated at short intervals. I have 
seen leeches serviceable, as well as the application of a large mus- 
tard plaster over the precordial region. Long-continued contra-irrita- 
tion on the chest, with tartar-emetic ointment, is to be persevered in 
for a considerable time, and repeated at intervals, upon the least un- 
pleasant sensation in the chest. 

It is a great matter to be able to say, whether or not there be any 
organic disease of the heart; and although the stethoscope is said 
not to be so useful in diseases of the heart as of the lungs, yet, in a 
majority of cases, taken along with other symptoms, we shall be able 
to determine this point with sufficient accuracy. If there be no dis- 
ease of the heart, very large opiates, united with colchicum, will be 
occasionally found singularly beneficial; even in Terry's case, (p. 17,) 
this treatment was serviceable. If the bowels are in a bad state, a 
pill may be exhibited every second or third hour, composed of five 
grains of calomel, the same quantity of opium, and three or four 
drops of oil of croton. Many object to the use of opium in such 
cases, but without sufficient grounds. The celebrated John Hunter 
took opium, it is alleged, with an aggravation of the disease ; but the 
small doses he used were quite inadequate in such a severe disease. It 
is stated by Sir Everard Home, that John Hunter was advised to take 
wine, which he did accordingly, but found the paroxysms more 
readily brought on after it. Laennec speaks highly of magnetism in 
such cases, and although too much cried up at one time by medical 
men, he thinks it is too much neglected at present. He used it in the 
following manner: — " I apply," says he, " two strongly magnetized 
steel plates, of a line in thickness, of an oval shape, and bent so as to 
fit the part — one to the left precordial region, and another exactly 
opposite on the back, in such a manner, that the magnetic current 
shall traverse the affected part. This method is not infallible, any 
more than others employed in nervous cases; but 1 may say that it 
has succeeded better in my hands, in the case of angina, than any 
other, as well in relieving the paroxysm, as in keeping it off." And 
he subsequently assures us, that when the magnet affords little relief, 
a good effect has followed the application of a small blister under the 
anterior plate. 

Should our remedies unfortunately fail in producing relief during 
a paroxysm of angina pectoris, we have the consolation to know, that 






ANGINA PECTORIS. 473 

much may be done to prevent a return of the complaint if there be 
no organic disease of the heart. Fatigue and violent exercise, to- 
gether with all excesses, are to be carefully avoided, as also stimu- 
lants and the application of cold. The diet of a patient so circum- 
stanced must be light, and easy of digestion, and he should limit him- 
self to a certain quantity of food by weight: and he should not drink 
more than is necessary for the purposes of digestion. Assiduous 
attention must be paid to the state of the bowels, to prevent constipa- 
tion; and the patient should regulate himself by medicine, or other 
means, that he shall have one or two stools daily. 



10' 



CHAPTER TIL 
PERICARDITIS AND CARDITIS. 



PERICARDITIS. 



This is a disease, which is seldom so well marked in its external 
characters, as the importance of the organ affected would lead us to 
expect. It is sometimes so insidious as to produce considerable 
disorganization before severe symptoms appear to attract our atten- 
tion; at others, it creates constitutional disturbance, which indicates a 
disease of great severity; but our attention becomes fixed, perhaps, 
upon some local pain, at a distance from the seat of the disease, to 
relieve which, our best efforts are directed. In truth, as Laennec 
observes — " There are few diseases attended by more variable symp- 
toms, or of more difficult diagnosis than this." And he assures us 
that it is as frequently mistaken as recognized :— "This is the result 
(says he) of my own experience up to the present time; and to mine 
I may add that of many of my medical brethren, and among others, 
M. Recamier." Cullen confesses that he knew little upon this sub- 
ject — so little, that he has not devoted more than twenty-seven lines, 
in his work on the practice of physic, to the consideration of carditis 
and pericarditis ; and his concluding words are — " There is, therefore, 
upon the whole, no room for our treating more particularly of inflam- 
mation of the heart or pericardium." Nevertheless, he has given the 
following definition: — "Pyrexia; pain in the region of the heart; 
anxiety; difficult respiration; cough; unequal pulse; palpitation; 
syncope. All the systematic authors seem unfortunately to have fol- 
lowed this definition, in the descriptions which they have given of 
this disease, instead of copying from nature. 

By pericarditis, I mean an inflammation of an acute, subacute, or 
chronic nature, of the serous membrane which lines the pericardium, 
and also that which gives an external covering to the heart itself, 
and the roots of the great vessels. In describing the phenomena of 
this disease, it must be kept in recollection, that in this, as well as in 
other inflammatory affections, a great number of varieties occur, giv- 
ing rise to symptoms more or less urgent. In two or three instances, 
I have seen the symptoms so urgent, as to produce great affliction ; 
in these, the pain was situated in the region of the heart, increased 
on taking an inspiration, as well as by any considerable motion of 
the trunk, which produced a tendency to syncope; the breathing 



PERICARDITIS. 475 

anxious and irregular, rather than difficult ; cough but slight in pro- 
portion to the anxiety of the breathing; the countenance sharp, and 
peculiarly expressive of distress: the pulse was regular at first but 
small like a wire; it generally becomes irregular, however, during the 
act of speaking, and when the patient moves. It is of great conse- 
quence, in all severe diseases, to compare the strength of the pulse 
at the wrist, with the action of the heart, by applying the ear in the 
same situation; and this precaution is peculiarly necessary in dis- 
eases of the heart and pericardium. In the latter, the pulse, as al- 
ready stated, is generally wiry and small, when the action of the heart 
itself is perhaps excessively strong, or I should have rather said tu- 
multuous. Even in insidious cases, an inequality will sometimes be 
perceived between the strength of the heart's action, and that of the 
pulse at the wrist. A case lately occurred to me of an insidious 
nature, which I shall briefly relate: — A middle-aged gentleman, 
having an extraordinary curvature of the spine, but who had never- 

. enjoyed robust health, remarkable for agility and muscular 
■trength, called at my house to seek advice. He told me that, for a 
week previously, he had been affected with an asthmatic complaint, 
which had now increased to such a degree, that he could scarcely 
take any exercise; that he passed sleepless nights; was alllictcd with 
con^h, attended by some expectoration; but he described his greatest 
■offering to proceed from violent spasmodic contractions affecting 
the muscles of the extremities. He had not lost much flesh, but 
laboured under considerable oppression and debility. On examining 
the chest, he was found to be somewhat chicken-breasted; he was un- 
able to fill. his lungs completely; the action of the heart was felt over 
a large space, tumultuous and irregular, intermitting occasionally six 
times in the minute, generally three or four; the pulse at the wrist 
having the same irregular and intermittent character, but it was 
small and weak in proportion to the strength of the heart's action. 

■I thai Ins appetite was had, thai it was almost impossible 
to keep his extremities warm, and that he chiefly attributed his coin- 
pi a mi ^ to 1 1 ttuleucy. I desired him to go home, and upon no account 
to venture abroad again. Next day I found him rather better, hav- 
ing had -.-ill copious stools, with which he passed a great quantity 
of flatus;— this was on Wednesday. On Thursday and Friday he 

nl 1 lined to improve; bul I had no doubt he laboured under an 
■ffection of the heart, and, much to his disappointment gave strict 
orders thai In; was on no aCCOUnl to go out. On Saturday, I found 
1 1 1 in verv ill, complaining of great oppression in his breast, and dilli- 

culty of breathing ; but Ins chief Buffering proceeded from cramps in 
his extremities, and occasional spasmodic rigidity of the whole body, 
winch was sometimes bent backwards, supported by the occiput and 

heels; and his landlady said, that the spasms were s,. severe during 

th'- night, that he could scarcely be kept in bed. He died suddenly 
mill" coarse of the following night On dissection, the brain was 

fbnnd l') he .pule healthy. No trace of disease was fmuid in the 

spinai cord except thai a very old adhesion was discovered, and two 

or three I,, -ales mi the surface of the arachnoid niem- 

Thfl pericardial!! was large, and contained a considerable 



476 PERICARDITIS. 

quantity of turbid serum, with a deposition of lymph, adhering in 
various places to the surface of the heart, but which was more abun- 
dant at the roots of the great vessels ; the heart itself was large, al- 
though it did not seem disproportioned in its different parts; the 
valves were sound. That I mistook the case, is very evident, and 
it is related expressly to show the circumstances which led me astray 
in the investigation. Had the individual not had a deformed spine, 
and severe cramps, I might, in all probability, have detected the true 
nature of the disease. I considered the dyspnoea to proceed from a 
nervous affection of the lungs, complicated with enlargement of the 
heart. Previously to the occurrence of this case, I would have de- 
clared it to be impossible for any one, labouring under pericarditis, 
to be able to walk more than half a mile up a hill, which this gentle- 
man did when he came to me on the Tuesday before his death; and 
when returning home, before he reached his lodgings, he had to 
mount three flights of stairs. — Since the publication of the first edi- 
tion, I have seen several severe and insidious cases, all of which were 
connected with acute rheumatic attacks. In one fatal case, there 
was no pain in the thoracic region, but the patient complained of op- 
pression, and was affected with slight dyspnoea; the action of the 
heart was tumultuous, and the pulse quick. The tongue was rough, 
deeply fissured and red. 

Laennec and other practical physicians agree, that, in the present 
state of our science, we are not acquainted with any symptoms 
which point out, with certainty, the presence of pericarditis. Per- 
haps this is more to be attribued to imperfect observation of the 
cases which have occurred, (very good examples of which are quoted 
above,) than to the obscure nature of the disease itself. M. Louis 
thinks that our ignorance of diagnostic signs is to be attributed to 
our imperfect observations — and in this opinion Dr. Scott concurs. 
According to these gentlemen, the observations of authors have 
generally been incomplete — many of the means of diagnosis have 
been neglected, and several circumstances of the greatest importance 
in forming an opinion of the nature of the disease, have been over- 
looked. From his own observations on this disease, and from an 
analysis of the cases on record, M. Louis is inclined to draw the 
following conclusions : — that pericarditis is characterized by pain in 
the region of the heart, sometimes extending to the back and epi- 
gastrium, attacking the patient suddenly, and accompanied with a 
greater or less degree of oppression, and in certain cases with palpi- 
tation — irregularity and intermission of the pulse, and more particu- 
larly by a dull sound in the precordial region, the other parts of the 
left side of the thorax remaining perfectly sonorous. Syncope 
sometimes also accompanies these symptoms, and occasionally infil- 
tration of the extremities — this probably takes place when the 
progress of the disease has not been very rapid ; but when it does 
appear, as it is one of the symptoms of disease of the heart, it ought 
particularly to fix our attention, and lead us to suspect an affection 
of that organ, or confirm our diagnosis, if we have already formed 
one. From the cases on record, Louis thinks that the disease may 
be detected in half of the cases where it exists ; and when free from 



PERICARDITIS. 477 

complication, he considers it to be as easily recognizable as the best 
marked pleurisy. 

Causes. — These are, generally speaking, the same as produce 
other inflammatory affections within the chest. It may be attributed 
to moral causes also, such as grief and anxiety ; and there can be no 
doubt that it is often occasioned by a metastasis during the course of 
rheumatism and gout. 

[Physical signs. — Oneof the most obvious of these is that derived 
from the attrition of the two surfaces of the pericardium, (which is 
roughened by the secretion of lymph,) and which has been com- 
pared to the grating or rasping of woad; or sometimes to the 
rustling of silk or the crackling of parchment; and Dr. Pennock 
adds that these friction sounds, when the effusion is inconsiderable, 
are first heard near the base of the heart; that they are almost 
always double, and frequently are triple or more; whence the term 
a to and fro sounds," in use among English writers. The friction, in 
strongly marked cases, is also perfectly sensible to the touch. 

Adhesion may be inferred from the cessation of these attrition mur- 
murs, and a strong jogging action of the heart, even though the fever 
has subsided.* 

Contrary to what might be anticipated, effusions of water in the 
pericardium (hydropericardium) are but obscurely detected by stetho- 
scopic signs. This condition does not take place until the disease is 
somewhat advanced, and is first detected by a circumscribed defi- 
ciency of sound, which extends more or less beyond the limits of the 
cardiac region, and sometimes occupying a large part of the left side 
of the chest. But if the effusion be complicated with diseases of the 
lungs or pleura, the diagnosis becomes yet more difficult and de- 
ceptive.] 

. Appearances on dissection. — There is very seldom any redness to 
be seen in the acute affection; but we always find flakes of lymph 
floating 111 a larger or smaller quantity of serum, and attached to the 
membrane itself. Sometimes the pericardium is amazingly distended, 
lining a quart, and even mora of tins fluid. When any n-dness 
i> observed, il is generally in small spots upon the surface of the 
pericardium. In some chronic cases, the pericardium is much thick- 
. and tin: heart enveloped with exudation. As Laennec very 
justly observes, il rarely presents the appearances of an equable 
membranous layer, like tin- false membrane of pleurisy, on the 

contrary, its surface \6 mOBl frequently marked by a great number of 
rough and irregular prominences. If the patient survive the first 
effects of the effusion, thelymphy part becomes quickly absorbed, and 
afterward* we find the-albominoua matter slightly glueing the pericar- 
iliiiin to tli.- heart I have seen sunn' cases where there was appa- 
rently no serous effusion, but a considerable quantity of lymph thrown 
ont every where over the heart. Occasionally, we find tne pericar- 
dium closely attached '<> the heart, forming a dense flbro-cartilaginous 
of being separated, even by dissection, Within these 
few years, I have Been two cases of tins sortj one individual died 

* I ton. Lnr,, 1 itat. 



478 PERICARDITIS. 

during an attack of erysipelas, from the united effects of inflammation 
of the membranes of the brain and mucous membrane of the lungs: 
the disease in the pericardium must have been of very long standing, 
but he enjoyed, nevertheless, excellent health, and great activity of 
body and mind, up to the period of his last illness. The subject of 
the other case was a young athletic man, who died from inflam- 
mation of the substance of the brain after a very short illness. About 
a year before, he had a severe indisposition, which was supposed to 
be hepatitis, and treated accordingly. After being in considerable 
danger, he gradually recovered health and strength. On dissection, 
the pericardium was found thickened and indurated, adhering firmly 
to every part of the heart, it being impossible to separate it in many 
places, even by careful dissection, without taking away the proper 
membrane of the heart. These two cases, and several others which 
I could quote, completely disprove the assertion of Corvisart, that no 
person can live, and preserve a good state of health, who is affected 
with a complete and close adhesion of the pericardium to the heart. 
On other occasions, the false membrane appears to be converted into 
cellular substance; and, although united to the heart, the adhesions 
are loose and long, and the pericardium can be easily separated. 

On the surface of the heart, we sometimes observe opaque, white 
spots, generally of an oval figure, about an inch in length, sometimes 
much smaller, and at others, very much larger. A great difference 
of opinion prevailed respecting the true nature of these spots. From 
my own observations and examinations after death, I have no doubt 
that they are the result of a partial inflammatory action on the sur- 
face of the proper covering of the heart. I used formerly to find it 
impossible to separate these in such a manner as to prove whether 
they were on the outside or beneath the serous membrane. At last, 
after submitting the parts to maceration for a few days, I have been 
able to remove them completely from the heart, leaving the serous 
membrane untouched, and apparently in a healthy state. — Baillie 
and Laennec are of the same opinion ; Corvisart, on the other hand, 
considers these productions to be situated beneath the serous mem- 
brane, and entirely unconnected with inflammatory action. 

Laennec states, that a tuberculous formation may sometimes take 
place, and thereby convert the acute into the chronic disease, as it 
frequently happens in the case of pleurisy and peritonitis, of which 
he has seen two instances; a third is noticed by Corvisart; and I 
have seen one case of it myself, in a man who died of a surgical dis- 
ease, quite unconnected with that of the heart. 

The muscular substance of the heart, in many of these cases, looks 
whitish, as if it had been macerated. Corvisart, and many others, 
suppose this loss of colour, particularly, when attended by softening, 
to be a sign of inflammation in the substance of the heart itself; but 
I feel disposed to join Laennec in doubting the correctness of this 
opinion. He states, that we can never be sure of the existence of 
inflammation in a muscular organ, unless we find a deposition of 
pus, or lymph among its fibres. 

[Adhesions of the two surfaces of the pericardium are a frequent 
result of their inflammation ; and we would, a priori, infer that this 



PERICARDITIS. 479 

condition in so vital an organ, would tend to cripple and rapidly to 
extinguish the motions of the heart. Extensive observations made 
by the pathologists of Europe, prove this not to be the case ; and 
such, also, is the result of my own experience. I attended a woman 
in the lower walks of life who died of protracted phthisis. On ex- 
amining the heart, it presented continuous adhesions over nearly the 
whole anterior surface, not less than three inches in diameter ; yet 
there was no remaining disease, nor had the patient during her ill- 
ness complained of pain or uneasiness in that region. The pericar- 
ditis had probably occurred a long time previous, and its results had 
in no appreciable way impaired the subsequent actions of the heart 
itself. 

Granulations not unfreqnently follow pericarditis. They may 
occupy or cover either surface of the pericardium, and sometimes 
attain a magnitude and abundance which would seem wholly in- 
compatible with the heart's motions. A very remarkable case of 
this kind occurred a few years since in the practice of Dr. Space- 
man, of this city, in the person of a negro of forty years of age. 
Having been invited to examine the diseased parts, I made draw- 
ings of them which, together with Dr. Spaekman's account of the 
appearances on dissection, were subsequently published.* The en- 
tire internal surface of the pericardium, as well the reflected portion 
as that covering the heart, was covered by a preternatural deposir, 
iti some places constituted of small, irregular, granular masses, ex- 
tremely vascular, and varying in size from a pin's head to a small 
bean. These caruncles were, in some places, so grouped as to form 
pendulous excrescences, especially towards the base and apex of the. 
heart, and on the reflected pericardium; and some of these were as 
large as an almond. The pulmonary artery was contracted at its 
exit from the right ventricle from similar excrescences, and the peri- 
cardium was enormously distended with water; but the heart itself, 
excepting a partial dilatation, showed no evidence of disease.] 

Treatment. — If the disease be detected early, there can be no 
doubt of the propriety of general bleeding, carried to the utmost 
extent the patient can bear, and repeated or not, according to cir- 
OOmstances. Leeches are to be had recourse to, when necessary; 
and u must be recollected, in treating an inflammation of a vital 
organ, that decision and promptness are of the utmost consequence 
to the patient. Antimony is to be used, together with contra-irrita- 
tion. Purgatives must be occasionally employed, together with the 
strict antiphlogistic regimen. 

If called late to a case, and when general blood-letting would he, 
perhaps, attended with immediate danger, we must have recourse to 
local abstraction of blood, by means of leeches, and throw mercury 
into the system aa quickly as possible. I am disposed to attribute 
the recovery of the last of the two eases already quoted, (at page 

127,) in which the pericardium was (blind attached to ihe heart, to 

the action of the mercury, winch was administered tor ihe Bupposed 
hepatitis. 

[• Philad. Journal ollhc Mc.l. <t Phys Sciences, vol. 3, N. S.] 



480 CARDITIS. 



Inflammation of the proper or muscular substance of the heart is 
a very rare disease: I have seen only one case of it, which was 
treated for the affection commonly known by the term angina pec- 
toris. The symptoms were unusually acute, and continued for four 
or five weeks, the patient never passing a night without fever, and 
never two days without having several severe paroxysms of suffering. 

In general, however, the symptoms are represented as being simi- 
lar to those which arise from inflammation of the pericardium, and 
it appears probable that the two diseases have been often confound- 
ed. [No stethoscopic sounds have yet been discovered which enable 
us to detect the inflammation of the heart, not even when ulcers and 
abscesses have formed.] 

Appearances on dissection.— Redness, and even injection of the 
capillaries, are equivocal signs of inflammation of the heart; so is 
some degree of softening of that organ, which, although sometimes 
observed after symptoms which indicated disease of the heart, yet is 
oftener seen when such signs did not exist; and I am convinced that 
the state which is usually noted down in reports of dissections, as 
softening of the heart, is frequently nothing more than the natural 
progress towards decay. Laennec states, that he has met with only 
one instance of an abscess in the walls of the heart. The subject 
was a child twelve years old; the abscess was situated in the parie- 
tes of the left ventricle, and might have contained a filbert. [Par- 
tial carditis, however, has been often met with by the later patholo- 
gists, connected with ulceration and abscess, sometimes perforating 
the inter-ventricular or the inter-auricular septum; and it is this 
state of disease that usually precedes rupture of the heart. Even 
this frightful lesion is not always immediately fatal, for a solid coa- 
gulum, or fibrinous concretion, has been known to arrest the hae- 
morrhage for several hours.] In another case of a man of sixty 
years old, he found albuminous exudation, of the consistence of 
boiled white of egg, and of the colour of pus, deposited among the 
muscular fibres of the left ventricle. " The patient had presented 
symptoms of an acute inflammation of some of the thoracic viscera, 
without precisely indicating its site. Orthophoea, and a feeling of 
inexpressible anguish, had been the chief symptoms." (Page 621.) 
In the case to which I have already alluded, a deposition of a mat- 
ter, whether pus or lymph could not be determined, was found near 
the apex of the heart, in the substance of the left ventricle. I would 
particularly refer the reader to Dr. Gairdner's interesting case of car- 
ditis, recorded in the 2d vol. of the "Medico-Chirurgical Transac- 
tions of Edinburgh." The subject of it died of another disease, 
eight months after the original attack, and the following is an abstract 
of the appearances in the heart: " Near to the apex of the heart, 
we found a layer of dense, organized lymph, closely investing a part 
of the parietes of both ventricles. On attempting to separate a por- 
tion of this layer, it was found to be firmly united to the substance 
of the organ, dipping between its muscular fibres, in the form of 



CARDITIS. 481 

dense cellular tissue." (Page 241.) The symptoms in this case were, 
preternaturally violent and rapid action of the heart, and a sensation 
of throbbing in the temples, with headache. 

Ulcerations of the heart, according to Laennec, have been more 
frequently observed than abscess, but it would seem they are more 
common on the internal surfaces of the heart, than on the external. 
Dr. Baillie observes, that although authors have mentioned cases of 
abscesses and ulcers of the heart, he is persuaded they are extremely 
rare.* He also states that mortification still more rarely takes place. 
Lieutaud, however, notices it, and Dr. James Kennedy, lately of 
Glasgow, has published a most interesting paper upon this subject, 
in illustration of a case of acute carditis, terminating in gangrene of 
the heart, in the " Medical Repository" for April, 1S24, which is 
well worthy of perusal. It contains sufficient proof, not only of the 
author's skill in pathological inquiries, but of his critical acumen. On 
dissection, it is stated, that " twenty ounces of turbid serum were 
taken from the chest; it had an impure orange colour, and a fetid 
smell. The pericardium inclosed four ounces of a fluid in all re- 
spects similar. On the internal surface of this capsule, was much 
vascular net-work, dark, as if composed of injected veins. All parts 
of the heart, external and internal, exhibited distinct marks of hav- 
ing been the seat of gangrenous inflammation. They were preter- 
natnrally flaccid, and dark as the darkest coagulated venous blood; 
they could be easily perforated by the finger. When thus torn, they 
exhaled a putrid odour, but no blood exuded from their ruptured 
vessels. The left ventricle, in particular, was quite livid, and desti- 
tute of its muscular tenacity; it was a little firmer than cerebral 
structure. When lacerated, it threw out a most offensive smell, 
limiiar to the odour of putrescent animal substance. All the cavi- 
ties of the heart were empty; but the large veins, especially the 
abdominal, were loaded with grumous blood." (Page 279.) 

Treatment. — A similar mode of treatment as that recommended 
in pericarditis is to be followed. The result of Dr. Gairdner's case 
is a strong proof iii favour of large bleeding, which prevented the 
iction from spreading, and preserved life, even after exten- 
sive disorganization had taken place. He took thirty ounces of blood 
from a veiu in the arm, on the 16th March : on the 17lh, it was re- 
peated in the same quantity; and again on the 18th, the doctor 
. he " ventured" on another equally "copious" abstraction of 
blood. During that night, from the shifting of the bandage, the 
patient lost several ounces more, and subsequently had leeches ap- 
plied. 

♦ Morbid Anatomy, p. 90. 



Ji 



[ENDOCARDITIS.] 



[ENDOCARDITIS] 

[This disease is an inflammation of the internal lining membrane 
of the heart ; and we are indebted for our first knowledge of it to M. 
Bouillaud. It is characterized, in its early stages, by a variable and 
preternatural red colour, which is sometimes mottled with bluish or 
brown spots. Sometimes the whole surface is of a uniform scarlet tint, 
but the capillaries are not obviously injected. Again, the whole or part 
of rhe surface exhibits a violet tint ; and these and the other appear- 
ances we have mentioned even extend into the muscular structure 
of the heart. That these signs do accompany the incipient stage of 
endocarditis there can be no question ; but it is also certain that they 
may exist without the presence of inflammation ; whence Laennec 
long ago declared them of no pathological value unless they were 
accompanied by some collateral evidence of an inflamed state, such 
as thickening of the membrane, or injection of its vessels ; and the 
mere redness of the membrane, however intense, may be and often 
is nothing more than a stain of blood, which may be readily imi- 
tated by artificial processes, and is of itself not a positive test of in- 
flammation.* 

The next stage of the disease presents unequivocal characters ; 
such as the thickening and pufliness of the membrane, and effusion of 
lymph ; the latter becomes rapidly semi-organized, and assumes the 
form of vegetations or granulations. The false membranes form to 
a greater or less extent, either lining the cavity of the heart or even 
forming partial septa within it. Ulceration is another but very un- 
frequent attendant on endocarditis; and Bouillaud thinks the disease 
sometimes terminates in mortification itself. 

The prolonged duration of endocarditis produces the whole chain 
of morbid structures so familiar in adhesion, cartilaginous degenera- 
tion and ossification of the valves, especially in the left side of the 
heart, with consequent contraction and displacement of those struc- 
tures. The effused lymph is the original nucleus, which first ap- 
pears as a simple false membrane, and this finally passes through the 
several stages we have indicated, until it assumes the hardness of 
bone. The base and edges of the valves are most subject to these 
changes, of which more will be said in a succeeding section of this 
work.t 

The symptoms of acute endocarditis are inflammatory fever ; 
little or no pain, but rather a peculiar distress in the region of the 
heart, which sometimes becomes extreme and intolerable. The 
heart's action is violent and tumultuous, as is evident in the fre- 
quent, strong, bounding pulse, which sometimes imparts a jerking 
sensation to the finger. As the disease advances, these symptoms 
increase ; the pulse becomes very quick and irregular, the breathing 
difficult, the countenance anxious, and the whole frame restless and 
tossing, with a livid complexion and constant tendency to syncope. 

[* Laennec. 1 [t Chap. vi. Diseases of the Valves.] 



[ENDOCARDITIS.] 483 

In fact, all the characteristics of an extremely impeded and embar- 
rassed circulation of blood through the heart are seen in strong relief. 

Physical signs. — Independently of the dulness on percussion over a 
large surface, (and which is distinguished from that which occurs in 
hydro-pericardium by the obviously more superficial action of the 
heart,) we find the bellows sound strongly developed, which is some- 
times accompanied by a peculiar tinkling or ringing. This is in the 
acute stage; but as the disease advances, as it rapidly does, to a more 
chronic stage, auscultation still detects some modification of the bel- 
lows murmur, or the rasping, sawing or musical sound. But as 
these signs are also present in other diseases of the heart, and are 
even present, as we have shown, in a mere anaemial condition of the 
circulatory system, it requires often-repeated examinations considered. 
in reference to the external symptoms already described, to enable 
us to establish an unequivocal diagnosis. When the valves, however, 
become changed in tissue and position, as hereafter to be described, 
very little uncertainty remains; and yet, under these circumstances, 
the disease has become a secondary, and, in a great measure, an in- 
tractable affection. 

Treatment. — Nothing can be more obvious than the necessity for 
prompt and active depletion in acute endocarditis; not only to pre- 
vent fatal consequences for the present, but to ward off organic 
changes for the future. It is unnecessary to repeat the best means 
of attaining these objects, excepting to impress the importance of 
repeated leeching or cupping over the precordial region, conjoined 
willi a succession of blisters on the interscapular space. Perfect 
rest, the avoidance of all excitement and a very light regimen, need 
hardly be insisted on when they are so obviously indispensable. 

Dr. Hope states that in chronic endocarditis he has experienced 
the most satisfactory results from prolonging the mild use of mercury, 
so as to maintain a barely sensible effect upon the gums, for three, 
four, five or six weeks; simultaneously employing a succession of 
small blisters in different parts of the precordial region, restricting 
the patient to a ferinaceoua and light broth diet, and confining him 
to his bed foe the purpose of ensuring the utmost possible corporeal 
tranquillity. # ] 

[• Disease* of the Heart, p. 320.] 



CHAPTER IV. 
HYPERTROPHY OF THE HEART. 



Br hypertrophy of the heart is understood, a thickening or in- 
crease in the muscular substance of one or more of its cavities. This 
may, perhaps, be considered rather as an increase of nutrition than a 
real organic disease; that is to say, in its simplest state, it may con- 
tinue for an indefinite period ; it is seldom fatal of itself, and proves 
so, either from the causes which have given rise to it, or from the 
diseases which it may induce in other organs. 

Hypertrophy frequently exists without complication ; at other 
times, we meet with it combined with dilatation and contraction of 
the cavities of the heart, as well as ossification of the valves. In this 
class of diseases, as well as in most others, we are constantly to bear 
in mind, that when one organ labours under disease, others in a short 
time give evidence of participation. 

I shall describe this disease in its most simple state, and point out 
the leading symptoms which attend it; but young practitioners should 
be aware, that they must riot invariably expect to meet the disease 
under the precise form in which it may be delineated. After due 
deliberation, with regard to the different arrangements which have 
been adopted in treating of hypertrophy, I give a decided preference 
to that of Bertin, who describes it under three forms: 1. Simple hy- 
pertrophy, without change in the capacity of the cavities of the heart; 
2. With the increase in the capacity of the cavities of the heart— the 
active aneurism of Corvisart — the hypertrophy with dilatation of 
Laennec, which is the most common form of the disease ; 3. Hyper- 
trophy with diminution in the capacity of the cavities of the heart. 

Hypertrophy is more common in the left ventricle than in the right, 
and is occasionally met with in the auricles. When the whole heart 
is affected, it sometimes attains an enormous size, appearing, when 
the thorax is opened, to fill both sides of the chest. 

In the natural state, the heart is about the size of the closed fist of 
the subject, not tightly clenched. The thickness of the walls of the 
left ventricle is more than double that of the right, and of sufficient 
firmness not to collapse when cut into. The right ventricle collapses 
when divided ; it is a little more capacious than the left, and the 
columnar carnas are of a larger size. 

In the diseased state, we sometimes, find the heart three or four 
times the above-mentioned size ; and when the left ventricle is af- 



HYPERTROPHY OF THE HEART. 435 

fected, its walls are frequently more than an inch, or even an inch 
and a half in thickness ; the greatest increase is at the base of the 
heart, decreasing towards the apex, although this rule is occasionally- 
reversed. The columnae carneae also require a proportionate enlarge- 
ment, and even the septum between the ventricles participates in the 
disease. 

The capacity of the ventricle is sometimes so much diminished, 
that Laennec informs us, in a heart double its natural size, he has 
seen it so small as scarcely to contain an almond in the shell. In 
such cases, the apex of the heart is blunted, and formed entirely by 
the left ventricle, which appears to constitute the whole of the heart, 
the right looking more like a process of it. 

In hypertrophy of the right ventricle, the thickening is never so 
great as in the left, and it is more uniform. 

The causes of the disease have been already alluded to. The in- 
crease of the nutrition of the heart has been compared to that of the 
muscles of the arm of the blacksmith : and all causes capable of in- 
creasing the action of the heart have been assigned as the sources of 
hypertrophy ; such are all affections of the lungs, impeding or retard- 
ing the circulation between the right and left cavities of the heart; 
and there can be no doubt, that individuals of a sanguine and ple- 
thoric temperament are most subject to this disease. 

Signs of hypertrophy of the left ventricle. — The general symp- 
toms have been already mentioned. In this disease the patient is 
less subject to violent and sudden attacks of palpitation than in dila- 
tation, but he is more sensible of the constant action of the heart. 
On applying the hand to the chest, it is met by a strong and extend- 
ed pulsation, sometimes as if the whole heart were raised against 
the hand, at other times only its apex. The pulse is generally full, 
strong, and vibrating, appearing as if the artery were constantly dis- 
tended. The raising of the ribs is quite visible, and in hypertrophy 
with increase of capacity, the action of the heart can be heard at 
some distance from the patient. 

Tin- Bound on percussion is dull, and on applying the stethoscope 
between the cartilages of the fifth and sixth ribs, a very Btrong im- 
pulse is felt, sufficient to raise the head of the observer, and accom- 
panied with a duller sound than natural — it is more prolonged in 
proportion as the thickening is more considerable. The contraction 
of the ventricle is very short, and productive of little sound, unless 
the disease be complicated with considerable dilatation. 

We must, therefore, distinguish between simple hypertrophy and 
hypertrophy with increase in the capacity of the cavity. In the for- 
mer, tin; sound is confined to a very limited spate ; n is scarcely per- 
ceptible under the left clavicle, and forms a remarkable contrast to 
the force of the shock. In the latter, the intensity of the sound is 
id— we have the strong impulse as in hypertrophy, and tho 
loud sound as in dilatation. The sound is sometimes so great, as 

tO be heard over every part of the chest. The pulsations of the 

carotid and other arteries are frequently visible. 

Signt of hypertrophy of the fight rent ride. — The signs arc pre- 
cisely the Bam d: that is to say, the heari. 

11* 



486 HYPERTROPHY OF THE HEART. 

plored by the cylinder, gives similar results, with this difference : 
that the shock of the heart's action is greater at the bottom of the 
sternum than between the cartilages of the fifth and seventh ribs, 
which is the reverse of what takes place when the disease is in the 
left side of the organ. This sign, drawn from the place where the 
heart is heard beating with most force, according to Laennec, is in- 
fallible. Lancisi described a swelling and pulsation of the jugular, 
as a sign of aneurism of the right ventricle. This symptom was 
rejected by Corvisart, who says he has seen it when hypertrophy- 
existed on the left side. Laennec differs with Lancisi, and informs 
us, that he never met with it in hypertrophy of the left ventricle, un- 
less there existed at the same time a similar affection of the right; 
while he has uniformly seen it whenever the right side was affected 
in a severe degree. We may, therefore, regard this as a pretty cer- 
tain sign. 

Hypertrophy of the auricles, considered as a disease, is not of fre- 
quent occurrence, and therefore is not of so much importance — it 
appears to be always consecutive to some other affection — either to 
a disease of the valves, or some obstacle to the circulation. If Laen- 
nec's notions respecting the sounds produced by the heart's action 
be incorrect, it follows that many of his stethoscopic indications must 
also be erroneous. It* is believed by some, that violent impulse of 
the heart depends upon hypertrophy of the auricles; I have no 
doubt that occasionally this is the case, but I am inclined to attri- 
bute this phenomenon to the increased bulk of the left ventricle. 

Hypertrophy is sometimes primitive, but is, perhaps, more fre- 
quently consecutive to some other disease. It commonly proves 
fatal by the effects produced on other organs, more especially the 
brain and lungs. 

No fact is better ascertained than the influence which hypertrophy 
exerts in producing apoplexy, as well as softening of the brain. . The 
attention of practitioners has been particularly called to this, by Le 
Gallois, Richerand, Bricheteau, Lallemaud and Berlin; and it is 
somewhat surprising to find a learned editor of the Edinburgh Medi- 
cal Journal, informing us, in 1»2S, that « no pathologist has par- 
ticularly examined those effects to ichich the diseases of circula- 
tion give rise in the cerebral organ,''* appearing to claim this as a 
discovery of his own, as well as the making of incisions in whittloes ! 
There never were individuals who better understood the mystery 
" of hanging great tveighls to small wires" than the editors of this 
debilitated and puffing periodical. 

Treatment. — Whether the analogy between hypertrophy of the 
heart and the muscles of the blacksmith's arm, be true in a patho- 
logical sense or not, I could quote a number of cases in which it is 
supported by the result of medical treatment; viz.: venesection, the 
strict antiphlogistic regimen and perfect rest. Of all diseases of the 
heart, hypertrophy is that in which the starving treatment of Valsalva 
will, in general, be found most advantageous, even when complicated 
with some degree of dilatation. 

The lancet is necessary in those cases-only in which we are ob- 
liged to diminish plethora more quickly than can be done by diet and 



HYPERTROPHY OF THE HEART. 487 

purgative medicines, and reduce the violent action of the heart, when 
danger is threatened to the brain or lungs. It is necessary to keep 
the patient quiet, with respect to bodily and mental exertion, and to 
prevent him from speaking. Great benefit is frequently obtained. 
from the occasional use of a weak solution of antimony, so as to pro- 
duce a slight degree of nausea. He should sleep in a well-aired, 
apartment, remote from every noise, and under as few bed-clothes as 
possible. With respect to his diet, it will be sufficient to say that it 
ought to consist of biscuit or toasted bread, in such quantity as will 
barely keep soul and body together. The quantity of fluid should 
also be regulated, and must at once be considerably reduced. Should 
lie complain of hunger, or be inclined to take liberties with himself, 
he may be readily enough controlled by two or three additional doses 
of antimony, which for that purpose should be given in different 
forms— sometimes in solution, to which substances may be added to 
change the colour — sometimes in powder, and sometimes in the form 
of pill. If there be any pain in the region of the heart, the occasional 
application of leeches is advisable. The length of time necessary to 
persevere in the use of this restricted regimen and treatment, must 
entirely depend on the severity of the symptoms, the nature of the 
disease, and the prospect we may have of being able, ultimately, to 
cure the affection. I have seen this plan beneficial within a few 
hours, particularly in two cases. The subject of one was a physician 
whose complaints had been gradually stealing on for many months; 
his hair dropped out; he became emaciated; he felt considerable 
debility, with impaired appetite; his nights were restless; but I was 
not sent for till dyspnoea and oppression in the chest were so great as 
to threaten speedy death. I found the impulse of the heart very vio- 
lent, probably the organ was in a slate of hypertrophy, and lie was 
threatened with haemoptysis. After bleeding him to sulficient ex- 
tent, li'; was put under the antimonial treatment, and starved; not- 
withstanding which, he began to increase in flesh and strength as 
. as the antimony was omitted, and he had perseverance enough 
to live for :i considerable time on two biscuits a day, talcing only as 
much fluid ;is was Buffietent to enable bis stomach lo digest them. In 
the course of - mi' 1 time, he was allowed to take a little fruit, which 
with his stomach, produced indigestion and flatulent dis- 
. >n, and oca lone I a temporary return of the former symptoms, 
proving, in a remarkable manner, the necessity of keeping the state 
of the stomach and bowels constantly in view, when treating diseases 
of the heart ; and I bo heartily coincide with the excellent remarks of 
Dr. I this subject, that I cannot forbear quoting his words. 

•• One great principle," ay • he, note, p. 687, ■• is of paramount im- 
nce; it is the removal of all disorders in other organs, which can 
of irritation to the heart; I would here add, that from 
its powerful influence gastric irritation) in stimulating the organs of 

circulation (o in stion, its prev i enre becomes essential to 

remedying the disease of ihe heart.*' 
r gentleman gradually recovered, and in nine mouths was able 
lo accept a medical appointment in India— -at the period -of his de- 
parture he appeared m perfect healthy bad recovered his flesh and 



488 HYPERTROPHY OF THE HEART. 

appetite; he lived like other people, and there was no unusual im- 
pulse in the region of the heart. I received two letters from him 
after his arrival in Calcutta, but the event happened which was much 
to be apprehended. The excitement produced by the heat of cli- 
mate and mode of living soon made an impression upon his frame. 
He was at length obliged to leave India, and died on the homeward 
passage. » 

The other case to which I have alluded, occurred in the person of 
a gentleman who had been indisposed for six months; and although 
the case was complicated with dilatation, and perhaps disease of the 
valves, he felt the benefit of the treatment in a few hours, and en- 
joyed sound sleep that very night, for the first time since his illness. 
He increased in strength and flesh; the impulse of the heart daily 
declined ; the agony which he felt in the chest, and outwards to the 
arms, ceased; cough, dyspnoea and expectoration with which he had 
been affected from the commencement of his illness, disappeared after 
the third day from the beginning of the treatment. This gentleman 
was able, in the course of a few months, to undertake a long journey 
to the southwest of England. This he performed without inconve- 
nience. He was distinctly told, however, that he could not be com- 
pletely cured, but might expect to be greatly relieved, and his life 
preserved for many years, provided he attended to his diet, and used 
proper precautions. Soon after his arrival in England, he fell under 
the care of one of those medical men who practise by routine, who 
have no pathological knowledge, but are never at a loss to give a 
name and local habitation to every disease that comes before them, 
who have a nostrum to cure every symptom, and who furnish their 
patients with eighteen draughts, three dinner pills, and a red mixture 
for three days' consumption ! ! Upon a first visit, he denounced the 
opinion of the "Scotch doctor," and declared that the patient's only 
complaint was "bile." He removed all my restrictions, told the 
patient to move about: to walk up the hills, which would open his 
chest and to eat beef-steaks and drink porter. All this was mighty 
pleasant news to the poor patient, who was very fond of the plea- 
sures of the table. But he was in the first place put under a course 
of mercury, during which he was confined to the house on account 
of the severity of the weather. Under this treatment, considerable 
amendment took place, and the most positive assurances were given 
of a speedy and a permanent cure. The most flattering accounts 
were received by the patient's friends in Scotland, who are people 
in the highest class of society; but my invariable answer was, that 
the amendment could not be permanent. Some months passed over, 
and still favourable reports were made. At length, having occasion 
to be in London on business, my desire to see the patient was so 
great, that I undertook two long days' journey solely for that purpose. 
On my arrival at his house, (at half-past ten o'clock at night,) I found 
he was out at supper. When he came home, he said he was pretty 
well, but felt the " old sensation always in his chest." On applying 
my ear to the thorax, I perceived a strong throbbing impulse over 
every part, with a loud rushing or blowing sound. It was a painful 
duty to be obliged to open the eyes of his affectionate wife to the 



HYPERTROPHY OF THE HEART. 489 

dangerous state of her husband's health, and the uncertainty of his 
surviving even a week. Fortunately for her future peace of mind, 
she believed me ; and, to shorten a long story, he died in less than 
three months. The correctness of my opinion was afterwards ascer- 
tained, and admitted by all parties. 

By degrees we are to allow the patient to return to an animal 
diet, which is better, when used in moderate quantity, than having 
his stomach filled with farinaceous food ; and in order to prevent 
either a wilful or an accidental error, the exact quantity of food 
allowed in twenty-four hours should be given by weight, and liquids 
by measure. 

The antimonial ointment is to be rubbed over the region of the 
heart, and irritation on the surface should be supported for a few 
weeks, every now and then, while the cure is going on. I think it 
best not to have recourse to it, however, till such time as the restric- 
tions of diet are about to be relaxed. 



CHAPTER V. 
DILATATION OF THE HEART. 



Dilatation of the heart consists in an enlargement of the capa- 
city of one or more of its cavities. Dilatation, complicated with 
hypertrophy, has already been described. In the morbid alteration 
now to be mentioned, the walls are much thinner than natural, com- 
monly conjoined with a degree of softening of the muscular sub- 
stance, and some change in the colour, which is either more purple or 
paler than natural. This disease is the "passive aneurism" of 
Corvisart. According to Bertin, who has written a valuable work 
on diseases of the heart, there are three forms of dilatation ; 1st. 
Dilatation with the thickening of the walls of the heart, which has 
already been treated of, under the title " Hypertrophy ;" — 2d. Dila- 
tation with thinness of the walls ; — and 3d. Dilatation without any 
change in the walls. Bertin has truly observed, that the orifices of 
the heart frequently partake of the dilatation of the cavities, inso- 
much that the valves become insufficient to close them. 

Dilatation is sometimes confined to one ventricle, though it more 
commonly affects both. The heart is more dilated in breadth than 
in length, and therefore assumes more of a rounded form than natural. 

The causes of this disease are ascribed by Bertin to some obstacle 
in the course of the blood, such as disease of the valves: this must 
be admitted ; but probably the most frequent cause is, as stated by 
Laennec, a congenital disproportion in the parts of the heart. In 
some cases, the foramen ovale is found open to a considerable extent. 

Symptoms. — Patients affected with dilatation are more liable to 
sudden attacks of palpitation and dyspnoea, on any violent emotion, 
than those with hypertrophy; the pulse is commonly soft, weak and 
undulating. Weak action of the heart, whether owing to dilatation 
or not, frequently produces alarming symptoms, such as vertigo, loss 
of memory, syncope ; together with nausea, vomiting, and consti- 
pation. 

J. M., aged 29, a medical student, very tall, stooping in his gait, of 
a fair complexion and light hair, had been affected for about a year 
with symptoms which he attributed to disorder of the stomach. He 
complained of a feeling of distension and weight in the epigastrium. 
Occasionally, he was troubled with a short, dry cough, and palpita- 
tion of the heart, excited generally by any sudden or unusual exer- 
tion. The pulse was naturally slow and full. 

These symptoms gradually became more constant and trouble- 



DILATATION OF THE HEART. 49 L 

some. In July and August, 1S23, he had occasion to exert himself 
considerably in his professional pursuits, and the feeling of uneasi- 
ness in the epigastrium and palpitation at the heart, proportionally 
increased, but appeared to him to be constantly relieved, when his 
bowels, which were generally costive, became relaxed by the use of 
medicine. 

In September, his complaints were much aggravated ; towards 
evening, the short tickling cough became exceedingly troublesome, 
and, when he placed himself in the recumbent posture, he was fre- 
quently seized with feelings of suffocation, which forced him to sit 
up. The difficulty of breathing, accompanied by a sensation of con- 
striction in the breast, was at times considerable; and the paroxysms 
which seized him during the nights, he compared to asthmatic fits. 
He was frequently obliged to rise during the night; and when he 
did sleep, was often suddenly awakened by a sense of suffocation. 
Towards morning, he became easier, and enjoyed some rest. Dur- 
ing the day, he was comparatively well. He was thin and pale, 
but complained little, except of want of rest. He went about his 
medical studies with ardour and assiduity; but on making any 
unusual exertions, he was immediately seized with the short cough, 
and, on mounting a flight of steps, or an ascent of any kind, he was 
often obliged to stop suddenly. On walking quickly, his strength 
failed, and he complained that his limbs refused to perform then- 
office. On examining the pulsation of the heart at this period, it 
appeared to be placed immediately under the hand; instead of the 
usual quick and hard stroke, a prolonged pulsatory throb was dis- 
tinguishable, extending over a larger than usual surface. To the 
stethoscope both the' left auricle and ventricle gave a clear, sharp 
sound, distinctly observable, also, under the clavicle of the right side. 
In October and November he became gradually worse. The pa- 
roxysms at night were more frequent and more troublesome; and he 
was generally Obliged to sleep in the sitting posture. lie sometimes, 
how 'l days and nights pretty comfortably, and he believed 

that this was principally the case when his bowels were freely 
opened. 

In December, the oppression and sense of fulness in the epigastri- 
um Increased to so great a d< -irree as to render the slightest pressure 
on the- part insufferable. The veins of the neck were observed, at 
this lime, to be lull, and a strong pulsatory motion was given to them 
above the clavicle. He still continued his studies with ardour, and 
refused (■> confine himself; hut on mounting stairs, or walking quicker 
than usual, he became completely exhausted, and was often obliged 
to rest himself. On the 12th December, he felt much worse, and 
Weaker. On the 14th, a material change for the worse had taken 
place; his face was p;de ami anxious, the lips bluish, and the ankles 
(edematous; — still he conversed cheerfully, and Without the least 
alarm. Tie' pulSS was small, and about 12'). On applying the 
hand to the region Of the heart, the usual quiek, hard heal, was not 

to be felt; but there was a kind of violent pulsatory struggle pet- 

eeptible over a considerable space. A physician saw him, and the 

medicines ho recommended were employed with great apparent bene- 



492 DILATATION OF THE HEART. 

fit. Mr. M. thought himself better; the oedema of the legs disap- 
peared, and the cough became less troublesome; — the palpitation at 
the heart had subsided ; and he complained only of a sense of weight 
in the epigastrium. During the day, he was tolerably well, but 
about ten at night, he became hot and exceedingly restless, continu- 
ally shifting his posture in the vain hope of repose. This continued 
for some hours, when he generally sunk into a slumber, and con- 
tinued till morning bathed in a copious perspiration. On Friday 
26th, he was much worse. At 4 p. m. he was sitting up and convers- 
ing cheerfully ; but his legs were more swollen ; his pulse irregular; 
the pulsation of the heart could not be felt in the usual place, and 
an undulatory pulsatory feel was communicated to the hand, when 
placed on the epigastrium. About 8 o'clock, his breathing became 
oppressed, he sunk into slumber, and died without a struggle. 

The body was examined about sixty hours after death. A great 
quantity of bloody serum seemed to have escaped, and still continued 
to flow from the mouth and nostrils. The body was much swollen, 
and the cellular membrane was distended with air; a quantity of 
serum flowed out on making the several incisions. About a pound 
and a half of bloody serum was found in each cavity of the thorax. 
The pericardium contained about three ounces of fluid. The heart 
was more than three times its usual size. It was of a deep brown 
colour, and destitute of fat. On examination, the right auricle was 
greatly increased in capacity, and extremely thin in its walls. The 
foramen ovale was sufficiently open to admit the point of the little 
finger into the left auricle. The right ventricle was nearly natural, 
as was also the left auricle. The left ventricle was of an enormous 
magnitude, and more resembled a large bug than a ventricle of the 
heart. It was more than three times its natural size, its walls of ex- 
treme thinness, and the fleshy columns widely separated from each 
other. The lungs were more than usually congested with blood; but 
they, as well as the viscera of the abdomen, were perfectly healthy. 

The above case is interesting in many respects, and among others, 
in having the foramen ovale open, which was, in all probability, 
produced by the enormous dilatation of the right auricle ; it is wor- 
thy of remark, that the communication between the right and left 
auricle existed without producing the diseases termed cyanosis or 
blue skin. 

Signs of dilatation. — The only certain sign is the clear sound of 
the heart with deficient impulse. Laennec says, the degree of dis- 
tinctness of the sound and its extent over the chest are the measure 
of dilatation; thus, when the sound of the contraction of the ven- 
tricles is as clear as that of the contraction of the auricles, and if it 
be at the same time perceptible on the right side of the back, the 
dilatation must be extreme. 

Signs of dilatation of the left ventricle. — A clear and sonorous 
sound between the fifth and seventh ribs of the left side. 

Signs of dilatation of the right ventricle. — The sound is heard 
somewhat better towards the bottom of the sternum than in the 
region of the heart; to which may be added, in the language of Cor- 
visart, a "greater degree of oppression, more marked serous diathe- 



TUBERCULOUS AND OSSIFIC FORMATION. 493 

sis, more frequent haemoptysis, and a more livid state of the counte- 
nance," than in affections of the left ventricle. 

According to Laennec, the most constant and characteristic of the 
equivocal signs of this affection, is, an habitually swollen state of the 
jugular veins without pulsation. 

The following statements are extracted from the work of Senac 
(Traite du Cceur, torn. 2.) — " 11 est certain que les dilatations des 
diverses cavites (du cceur) peuvent etre distingue'es. En general les 
Lattements du cceur ne sont pas violents quand le ventricle droit, 
ou le sac de ce ventricle, sont extremement dilutees; a peine les dila- 
tations produisent elles des palpitations; dans beaucoup de cas, 
les malades sentent seulement un grand poid dans la ?'egion du 
cceur" page 327. And again, " Les dilatations du ventricle droit 
et de son oreilletle, produisent toujours des battements dans les 
veines du col " " Z,' absence de ces battements, lorsqu'une dila- 
tation du cceur est constatke, itablit cette dilatation dans le ven- 
tricle gauche," &c. Page 328. 

My attention has been frequently attracted to dilatation of the auri- 
cles, since the publication of the first edition. In several instances, 
the auricles, instead of forming a small part of the whole organ, were 
of equal size with the ventricles; in others, the proportions between 
auricles and ventricles were reversed — the former being by far the 
largest part of the heart. I have occasionally found the walls of the 
auricles much thickened, not only with respect to the muscular struc- 
ture, but the lining membrane also. In a healthy heart, the lining 
member of the auricles is considerably thicker and stronger than that 
of the ventricles; but in the condition of which I am now treating, 
the contrast is very remarkable. 

In concluding this part of the subject, it may be observed, that we 
have frequently combinations of different diseased states; thus we 
occasionally meet with dilatation of one ventricle, and hypertrophy 
ofthe oilier; but the comparative exploration of the two sides of the 
heart will enable us to detect this, after some practice with the ste- 
thoscope. In other cases, we have dilatation of one ventricle and the 
opposite auricle. We also meet with cases in which the parietes of 
tbe dilated cavity are thickened in certain points of their extent — 
thinned in others — and in the remaining parts exhibiting their natu- 
ral structure. 



TUBERCULOUS AM) OSSIFIC FORMATION IN THE 

SIBSTANCE OF THE HEART. 

V kBiouv kinds nf accidental productions have been found in the 
ce of the heart. 1 shall merely mention the enormous collec- 
tions of fat which have D660 discovered aboUl the | ><i ir;i i < ! iuiri and 

heart, becatl ■• I have mtii this condition frequently in subjects who 
have died nl' other diseases, and in whom no affection of the heart 
had been BUSpected j at the same tune, there are cases on record, m 



494 ATROPHY OF THE HEART. 

which the muscular structure was so much weakened, and the fibres 
so much separated by the interposition of fat, that it has appeared to 
be the cause of impeded action, and occasionally of rupture of the 
organ. 

Ossific depositions in the walls of the heart are avowedly rare. 
Laennec met with two instances of this formation between the layers 
of the pericardium ; the history of one of the cases, along with the 
dissection, (at p. 670 of the translation,) is well worthy of perusal. 
Baillie notices instances of this nature; one case fell under his own 
observation, in which the ossification had spread over a considerable 
portion of the pericardium, (p. 13.) He also says, (at p. 49,) " When 
a part of the heart is converted into an earthy matter or bone, no 
morbid symptoms whatever have in some cases been observed ; and 
in others, there has been palpitation of the heart, with difficulty of 
breathing." But the author does not say that he had ever seen such 
cases. 

I have seen one instance only of tubercular formation in the sub- 
stance of the heart; Laennec states that he has seen it three or four 
times. In the year 1S26, some of my pupils were called upon to 
examine the body of a young woman, who dropt down dead without 
any previous indisposition. No diseased appearance was found any- 
where but in the heart. On opening the pericardium, it was ob- 
served to contain a little serum. The surface of the heart was vascu- 
lar, and there was some watery effusion beneath the serous membrane 
at several points. There were also two considerable projections, the 
largest at the apex of the heart, the other about the centre of the left 
ventricle; on making incisions at those parts, tuberculous masses 
were found occupying the whole thickness of the organ, of a soft 
cheesy consistence, at the apex, to the extent of an inch and a half 
in diameter, and at the left ventricle to that of an inch. 

Upon inquiry, it was found that this individual had led a very 
irregular life, but had always enjoyed a good state of health. 

In my museum there is a preparation obtained from a cholera sub- 
ject, in which a considerable portion of the right auricle and ventricle, 
together with the coronary arteries, is ossified. The previous his- 
tory of the patient is not known. 



ATROPHY OF THE HEART. 

Diminution of size is mentioned by most authors who have writ- 
ten upon diseases of the heart. Laennec states, that " the heart like 
the muscles of voluntary motion, is clearly susceptible of diminution 
of size." The hearts of individuals who die of phthisis are ob- 
served to be uncommonly small: Laennec says, that he has thought 
he " could recognize a sort of withering of the organ indicative of 
its loss of volume." On examining the body of a young woman, 
who died from the effects of a tumour, weighing above fifty pounds, 
which grew from the fundus of the uterus, and extended upwards, 



RUPTURE OF THE HEART. 495 

encroaching so much upon the thorax, that the diaphragm on the 
right side was pushed up as high as the first rib, the heart was found 
little above half its usual size, and was very much flattened by the 
pressure of the tumour. Its action had been so much impeded, that 
the pulse could be scarcely felt in any artery of the body for a con- 
siderable time before death. I have another heart in my possession, 
taken from an adult male, which is not larger than that of a child of 
six years old. Both coronary arteries were found much ossified. 
In this case there could be no doubt that the small size of the heart 
depended upon the diminution of the nutritive process; the pulse at 
the wrist was exceedingly small for five or six months previously to 
death, and during the last two months, it was so weak that it could 
scarcely be counted. Laennec says, that he has never observed any 
symptom peculiar to atrophy of the heart. " I may remark, how- 
ever," lie adds, " that several hypochondriacs, who are liable to 
faintings from very slight causes, gave, under the stethoscope, signs 
of a very small heart; and we know, moreover, that women, who 
are much more liable to these attacks than men, have, in general, 
smaller hearts." (Page 614.) 



RUPTURE OF THE HEART. 

We are assured by those who have had the best means of know- 
ing, that this accident is very rare. Laennec thinks that these rup- 
tures are generally produced by previous ulceration of the ventricular 
parietes, and Benin is of the same opinion. Laennec states, that it 
is surprising rupture of the heart does not more frequently happen 
in those cases of great accumulation of fat, reducing the walls of 
the ventricles to extreme thinness. According to Meckel, rupture of 
the heart most frequently takes place at the point of junction be- 
tween the aorta and left ventricle ; but this does not seem to accord 
with the observations of others. Bayle assures us, that in nineteen 
of rupture of the heart, fourteen took place in the left ventricle, 
principally on its anterior side near the apex ; three in the right ven- 
tricle. In most of the subjects, the heart was remarkably soft, and 
the substance around the perforation was of a brown colour. Bail- 
lie's observations upon this subject are very vague, and not worthy 
of quotation. I have seen two cases of sudden death, in which the 
pericardium was found to contain a large quantity of coagulated 
blood. In one of these, the perforation through which the blood 
had issued, could not he discovered lor some time, and when on the 

point of giving up tin; examination, 'i small rent, just capable of ad- 

mitting the h"ad of a pin, was found at the root of the aorta, which 

[| was somewhat dilated, and us texture injured by incipient 

fication. — The subject of the other case was a woman about 
fifty years of age, who had previously enjoyed a good state of 
health. The nighl before hei death she had walked from the south- 
west extremity of the Old Town of Edinburgh to New Haven, and 



496 RUPTURE OF THE HEART. 

back again, a distance of about six miles, and had gone to bed with- 
out making any complaint. After a good night's rest, she got up in 
the morning, and fell down dead soon afterwards, whilst cleaning 
her shoes. On dissection, the pericardium was found greatly dis- 
tended with coagulated blood; the aorta, much injured by ossifica- 
tion, was seen greatly dilated near its origin, where a small rupture 
existed, not above two lines in length. 

Bertin mentions two instances of rupture of the auricles, which is 
more rare than that of the ventricles : in one of these, the rupture 
was produced by a fall ; in the other, it occurred without any per- 
ceptible cause, and the heart was enormously loaded with fat. 

We are assured by Laennec, that rupture of the auricles, ventri- 
cles, and large vessels within the pericardium, is not always followed 
by sudden death. In several cases, the blood accumulated in the 
pericardium formed a solid coagulum, and checked for a time the 
haemorrhage. 



CHAPTER VI. 
DISEASES OF THE VALVES. 



The valves of the heart are liable to depositions of fleshy, cartila- 
ginous, and osseons matter, which increase their thickness, alter their 
shape, and obstruct the orifices in which they are placed. They are 
sometimes so much altered in structure, as to be unfit to perform their 
chief function, viz.: to prevent the regurgitation of the blood. The 
valves at the origin of the pulmonary artery, have a remarkable im- 
munity from these diseases, while they are frequently met with in 
those at the aorta. The mitral valves are, perhaps, more frequently 
diseased than the tricuspid.* 

Appearances on dissection. — Sometimes the points only of the 
semilunar valves are affected ; at others, their bases; when they are 
affected throughout, they are deformed, and often coiled upon them- 
selves; and when in this condition, they have frequently a red fleshy- 
looking appearance, smooth, and polished. Very often a small car- 
tilaginous concretion is observed in the points of the semilunar valves, 
which may be considered as enlarged corpora sesamoidea, but which 
catj scarcely impede the circulation, until they become of consider- 
able size. Sometimes these valves seem, as it were, to be encrusted 
with osseous matter; and I have seen instances in which it was im- 
possible to trace the inner membrane over the osseous projections. 
■ in Mm'- find small fleshy vegetations resembling warts. 

'I'le' cartilaginous induration of the auriculo-ventricular valves is 
sometimes confined to tin; fibrous bands found in its base. In this 
case, it has the appearance of a very smooth, though unequal ring, 
diminishing the size of the orifice; it is sometimes of a semi-cartilagi- 
nous consistence; at others, it is formed of perfect cartilage. The 
same kind of appearances is occasionally met with in other parts of 
these valves, but those situated at the bases and points are usually 
the thickest. 

The o sous productions are found in the same situations, and are 
very unequal as to thickness. Like those already described in the 

Semilunar valves i)f the aorta, they are often found projecting from 

the valve, denuded and eery rough. We are assured by Lacnnec, 
that they are not perfect bone, being whiter, more opaque, more 
fragile, evidently containing a greater proportion of phosphate of 

lime. They are sometimes situated on the free nmrgius of this valve, 

[• The pathology of the morbid changes have bceo explained in the section on 
trditto.] 



498 DISEASES OF THE VALVES. 

diminishing greatly the size of the orifice ; indeed, sometimes to so 
great an extent, as scarcely to admit the blade of a pen-knife, of 
which there are examples in my museum. Sometimes, though 
rarely, the tendinous chords of the mitral valve are affected in a 
similar manner. In one case, Dr. Forbes found three of the pillars 
of the mitral valve completely ossified through their whole extent, 
with the exception of a minute portion at each extremity.* 

The auriculo-ventricular valves are likewise found studded with 
fleshy excrescences like warts ; they are, in general, soft, and with 
difficulty preserved. 

When ossification is confined to the free margins of the sigmoid 
valves, or when the base is affected, if still slightly thickened, the 
valve may perform its functions, provided the middle portion be still 
sound ; but when the disease is extensive, the valves, according to 
Laennec, grow together, and get incurvated either towards their 
concave or convex side, in which state they are immovable, being 
either fixed on the side of the aorta, or in the orifice of the ventricle. 

Symptoms. — These are palpitations and dyspnoea, often to such 
a degree as to be called asthma; both these symptoms are increased 
by quick exercise, or any unusual exertion or emotion. When the 
disorganization advances to a certain pitch, the palpitation and dys- 
pnoea increase in frequency and violence; the pulse is weak, small 
and thready, and occasionally intermits, which corresponds with 
intermissions in the contractions of the heart ; the feet are observed 
to become oedematous towards evening. At last the symptoms 
denoting impeded circulation, augment, the face and extremities 
become discoloured, the oedema extends to the legs, dropsical effu- 
sions take place into the different cavities, and the dyspnoea increases 
to such a degree, that the patient is obliged to remain in a sitting 
posture, or bent upon the edge of the bed, in a kneeling position. 

According to Laennec, the following stethoscopic signs are ob- 
served : " The symptoms of ossification of the mitral valve are little 
different from those attending the same affection of the sigmoid. 
According to M. Corvisart, the principal sign of the former lesion 
is 'a peculiar rustling sensation, (bruissement,) perceived on the ap- 
plication of the hand to the region of the heart.' This peculiar sen- 
sation is nothing else than the purring thrill already described. It 
is assuredly very frequently observed in the case of ossification of 
the mitral or sigmoid valves, when this exists in a high degree; but, 
as I formerly slated, it may exist when these valves are perfectly 
sound, and it is almost always absent when the induration is not so 
extensive as materially to obstruct the orifices. The bellows sound 
is a much more constant sign ; it accompanies the contraction of the 
left auricle, when the mitral valve is affected, and that of the ventri- 
cle, when the induration is in the sigmoid. But even this is wanting 
when the alteration is not extensive; and as it is, moreover, very 
common when the heart is perfectly sound, we must lay no stress 
upon it as a sign, unless it be combined with other circumstances 
calculated to confirm the diagnosis. Accordingly, when the sound 

* Original cases, p. 133. 



DISEASES OF THE VALVES. 499 

of the bellows, rasp or file, persists in the left auricle, either continu- 
ously or interruptedly, for several months; when it is found only 
then, and exists even in the greatest quietude ; when it is scarcely 
lessened by venesection, or when lessened, if it still leave behind it a 
degree of roughness in the sound of the auricle — or, yet more, when 
the purring thrill coexists with this, we may be assured that the au- 
ricuio-ventricular opening is contracted. If the same phenomenon 
occur under similar circumstances in the left ventricle, we may be 
equally certain that the aortal orifice is contracted." Three or four 
times, during the last four years, 1 have discovered this lesion by 
means of these signs. Three similar examples, equally verified by 
dissection, are recorded in M. Bertin's work,* and a fourth is given 
in the collection of cases published by Dr. Forbes; (Case vii.) "But," 
continues Laennec, ; ' if these phenomena exist only for a time, al- 
though as much as two or three months; if they accompany the 
increase of any other nervous or organic disease of the heart, we 
must not depend upon them as indications of the lesions now in 
question, since all the facts formerly recounted, prove that these 
sounds are not produced (as might be imagined at first) by the pass- 
age of the blood over a rough or rugged surface, but to the spasmo- 
dic energy requisite in the muscular contraction, to overcome the 
obstacles opposed to it. It follows, therefore, that any other cause 
besides diminution of the orifices, which occasions contraction of the 
heart, is equally capable of giving occasion to the bellows sound and 
purring thrill; and it is fair to admit, that in the first edition of this 
work, I laid too much stress upon these two phenomena, as signs of 
valvular disease. A slight degree of cartilaginous or bony indura- 
tion of the valves may exist for a long time without any visible alter- 
ation of the heart; or even by proper measures of precaution, and 
by seasonable bleedings, we may frequently preserve, for a long time, 
the life of individuals, who present every sign of considerable con- 
traction of the orifices." — (Forbes's Translation, page G34.) 

Laennec appears to have laid too much stress upon the effects of 
nervous affections of the heart; and in the latter period of his life he 
ip- timid and doubtful with respect to his own powers of obser- 
vation, which enables us to account for the tenour of the above quo- 
tation. I believe, however, that these sounds, and more particularly 
the blowing or rushing sound, may I"; occasioned by a large quan- 
tity pf blood rushing with violence through the orifices, even when 
the valves an; sound. 

Within these few years, several cases of sudden death have taken 
place, even in young persons, and the only morbid appearance dis- 
■ i upon dissection was disease of the valvular apparatus. 
Treatment. — A similar treatment to that formerly recommended 
in other diseases of the heart is necessary; viz.: to reduce and obviate 
plethora, to enjoin rest, and '<> avoid every cause winch can increase 
the quantity of blood, and hurry the circulation ; and lastly, to mode- 
rn symptoms by applying leeches, producing contra-irri- 
tation, and administering an occasional opiate. 

♦ Observation , ■!:», 68, 51. 



CHAPTER VII. 

DISEASES OF THE BLOOD-VESSELS. 



The first disease of this class which I shall notice, is inflammation 
of the internal membrane of the heart* and large vessels near it. 
Since the last edition was printed, I have had much opportunity of 
examining this part of the morbid anatomy. Previous to this, I 
thought inflammation of the internal membrane of the arteries " a 
very rare disease," but am now convinced it is by no means un- 
common. I have seen false membrane in every stage, from the 
commencement of a deposition of lymph, to its complete organiza- 
tion. There are many specimens of this in my museum. It appears 
to me that the atheromatous deposit, so often found in the arteries, 
particularly in the aorta, is frequently produced in this false mem- 
brane, and not so uniformly in the middle coat as has been hitherto 
supposed. Bertin has written to prove that inflammation of this 
membrane is a common affection. The lining membrane of the 
heart, and of the large blood-vessels, is sometimes found of a brown 
or violet colour, and also a bright scarlet. It is a subject of contro- 
versy at this moment, whether this colouring is the effect of disease, 
or of imbibition of blood after death. From my own observations, I 
am led to conclude, that it is sometimes from the one cause, and 
sometimes from the other; and I think our conclusions must depend 
upon three circumstances : Is/. Whether any blood is found near the 
discoloured portion? 2d. Does blood found in the aorta, always impart 
a colour to its lining membrane ? 3d. Upon the texture of the part so 
affected. I have frequently found the aorta of a red, brown, or violet 
colour, when neither it nor the left ventricle contained any blood; 
and, on the contrary, I have seen the aorta almost filled with blood, 
partly fluid, partly coagulated, when the inner membrane presented 
its usual straw colour. When the aorta was discoloured, I have oc- 
casionally found the inner membrane soft and pulpy, and readily 
removed with the fingers; and I scarcely remember to have seen in- 
cipient ossification of the aorta, without observing a vivid redness of 
its internal membrane. This subject ought to be held as being open 
to future investigation. The next point which has attracted the at- 
tention of pathologists, is the exudation of coagulable lymph. It is 
stated, that this has actually been found; Burns, for instance, dis- 
tinctly describes it: Laennec says, that he has observed false mem- 
branes of small extent, strongly attached to the walls of the auricles. 
The next subject worthy of attention is ulceration. Laennec seems 

[* Vide Endocarditis.] 



DISEASES OF THE BLOOD-VESSELS. 501 

very much inclined to doubt the existence of ulcerations in this deli- 
cate membrane; he supposes the parts, left by the separation of the 
bony incrustations of the aorta, to have been mistaken for ulceration; 
he states, however, that small pustules have been sometimes met with 
beneath the inner membrane of the aorta, and which have discharged 
their contents into its cavity; and he asserts, that it is probable that 
what are called ulcers of the aorta, are formed in this manner, being 
the consequence of inflammation of the middle coat of the arteries, or 
of the fine cellular substance which unites this to the inner coat. In 
quoting these statements, I have to remark, that Laennec appears to 
be determined not to admit that inflammation of these parts can exist, 
and that he has manifested too much of the spirit of a special pleader. 
The last point which some individuals suppose indicative of inflam- 
mation of the inner membrane of the heart and blood-vessels, is the 
formation of concretions, well known by the name of polypi. One 
set of pathologists maintains, that they are the result of previous in- 
flammatory action, which another denies. It is a most interesting 
question in pathology, and therefore deserves minute investigation. 
Since the publication of the first edition, two dissections have taken 
place in Edinburgh, which set this question at rest for ever — several 
polypi, organized and partially ossified, having been found in the right 
auricle in one case, and several polypi containing pus in the other. I 
am well aware that polypi, which have been termed " organized" 
have been frequently observed, and that injections have been thrown 
into the vessels; but doubts have been entertained on the subject, and 
the appearance of vascularity has been variously accounted for. The 
following is a short sketch of the first case above alluded to, and the 
appearances on dissection : — A young woman, of amiable disposition, 
and regular, industrious habits, died after several years' illness. I 
was requested to visit her some years before her death; she was then 
labouring under cough, quick and anxious breathing, palpitation, 
emaciation and hectic fever. One or both lower extremities were 
affected in a similar manner to that observed in phlegmasia dolens. 
1 1 « • i appearance was so unpromising, that I thought she could not 
BUrvive ; but she rallied, and for a time became better, but soon 
(gain; in fact she became better and worse at times, occa- 
rionally much distressed with dyspnoea, cough, pain and distension 
of the lower extremities, and febrile symptoms. It was thought that 
her lungs were affected, as the sound of respiration, during a severe 
paroxysm, was not audible in some parts of the chest. This opinion 
v b rabsequently abandoned, when it was supposed that the func- 
ti«njs of the lungs wen embarrassed in consequence of some impedi- 
ment in the circulation. The action of the heart appeared natural, 
but the sounds am! impulse were weak. There was no irregularity of 
pulse. Nothing afforded her any relief but venesection ; and during 

her illness, I am informed the was bled above one hundred times. 
The uneasiness produced l>y the tense, and swollen condition of the 

tower extremities, was greatly eased ii\- repeated punctures, when a 
quantity of serous fluid was discharged. 

On di l ie c tion. — The lungs arere somewhat rr.dematous, but ap- 
peared otherwise sound. The heart did not appear to be above the 



502 OSSIFICATION OF THE ARTERIES. 

natural size ; the right auricle was found almost filled by a large 
hard mass, which adhered by a broad margin to the superior part of 
the auricle, while its inferior portion projected into the corresponding 
ventricle; it was tightly held in this position by the tricuspid valve. 
The superior and inferior portions of this mass were converted into 
osseous matter, and felt hard to the touch. The centre part was in 
appearance like a hardened coagulum of blood ; and when the pre- 
paration was recent, there were thin ossific scales seen running in a 
longitudinal direction everywhere over the surface. In the same 
auricle, there were three other, but smaller masses. One was like 
a coagulum of blood, and adhered to the superior part of the auricle, 
between the orifices of the pulmonary artery and superior cava; ano- 
ther was small and carneous, attached to about the centre of the 
auricle, but which was broken off, and lost during maceration ; its 
base, however, is still to be seen in the preparation ; the third mass 
has not been examined. It lies deep in the auricle below the large 
ossified polypus, and we were fearful of destroying the attachments 
of the latter to the heart. The inguinal veins and the vena cava 
were found distended with hard coagulated blood ; on minute exa- 
mination the coats were found in a healthy state, perhaps somewhat 
thickened, but the contents adhered firmly to the sides of the vessels. 
In some parts, particularly on the right side, the contents of the veins 
were organized, completely obliterating the vessels. 

It does not appear that this condition of the lining membrane of 
the heart and arteries is indicated by any particular symptoms, 
although some assert that it is the cause of inflammatory fever. 



OSSIFICATION OF THE ARTERIES. 

The morbid condition which goes by this name belongs to the 
class of imperfect ossifications. These seem to be produced in two 
ways; — 1st, By soft cartilaginous depositions, which are gradually 
converted into ossifications by the deposition of small calcareous 
spots, which gradually extend. 2d. By the deposition of a soft pow- 
dery substance, without any cartilaginous formation ; this substance 
becomes gradually converted into ossific incrustations. Occasionally 
ossified spots are found only here and there, although sometimes the 
whole vessel is affected. Some pathologists imagine, that this for- 
mation invariably takes place between the inner and middle coats, 
and is not connected with inflammation — this appears to be Laen- 
nec's opinion; others maintain, that it is the consequence of inflam- 
mation. After careful observation, I have reason to believe, that 
atheromatous and osseous deposits are the product of inflammation, 
and that occasionally they are formed in the situation mentioned ; 
but that they are sometimes found in a false membrane, thrown out 
by inflammatory action of the internal coat of the arteries, admits of 
no doubt. When these depositions take place between the proper 
coats of an artery, the inner membrane in many parts is often even- 
tually removed, by exposing the bare ossified surface. This forma- 
tion is frequently the cause of aneurism. All arteries do not seem 



ANEURISM. 503 

equally disposed to take on this diseased action. The aorta, at its 
origin from the heart, is most frequently found affected ; then the 
arch, and the descending aorta, the disease attacking the angle at 
which the vessels branch off, in preference to other parts. The arte- 
ries of the brain are very frequently found diseased in cases of apo- 
plexy. I have seen the most minute vessel that could be traced in 
the brain, in this condition ; and on one occasion, the circulation on 
one side of the circle of Willis was completely obstructed from the 
ossification of the vessel. The pulmonary artery, and the arteries 
of the superior extremities, would seem to enjoy a singular immu- 
nity, whilst those of the lower extremities are often affected. Ossi- 
fication of the blood-vessels must influence the functions of various 
organs. I possess a beautiful preparation, showing its effects upon 
the kidney — one emnlgent being almost obstructed by ossification, 
while the corresponding kidney is in a state of atrophy. 



ANEURISM. 

There is no disease which shows the absurdity of the division of 
medicine into physic and surgery more than this. When an aneu- 
rism is within reach of the knife, then it is called a surgical case; if 
otherwise, it is handed over to the physician. All writers describe 
aneurisms of two kinds — the true and the false. I can join Laennec 
in stating that "true aneurism of the ascending portion and arch of 
the aorta is very common." I have seen it more frequently in such 
a situation than the false aneurism ; indeed, Laennec is of opinion, 
that false aneurism of the ascending aorta, or its arch, rarely, if ever, 
exists, unless formed by a rupture of the inner coat of a true aneu- 
rism, after it has acquired a certain size; at least he states that he 
had never met with any other species of false aneurism in that situa- 
tion, but that consequent to the true or simple dilatation of the part. 
The abdominal aorta is also the seat of aneurism : and the arteries 
of ili-: brain are not exempt. Aneurisms of the aorta exist in va- 
rious degrees, from slight dilatation, up to the size of the head of a 
1'iwn foetus. The vessel is found in one of three states: — 1*/. 
The walls more or less converted into ossific matter, looking scab- 
rous and irregular, portions, in scales, being easily separated; in 
many instances these scales are found loose, and already more or less 
detached:— Sol That in which the whole of the coats of the aneu- 
rism are entire, much thickened and cut under the knife like fibro- 
cartilage, having very much tin: same appearanee: — 3d, That in 
which a natural cure has been effected by the deposition of thick 
layers of coagulable lymph, filling up the aneurisinal sac, leaving 
sufficient space for the |>;isviu<: of the blood: — \th. That in which a 

portion "i the aneurisinal sue is entirely wanting, in consequence of 
long-continued pressure mi surrounding parts; so thai sometimes a 
portion of the Lungs, ami even the spine itself, have formed a part of 
the aneurisms! tumour, 

Aneurisms of the aorta produce various effects on the neighbour- 
ing parts, according to their size and situation. Laennec assures us, 



504 ANEURISM. 

that simple dilatation, when in a moderate degree, hardly produces 
any effect; but that the most inconsiderable false aneurisms may give 
rise to very serious disorder. The first and most common of these 
effects is compression of the heart and lungs, by impeding the circu- 
lation and respiration. When the aneurism is in contact with the 
lungs, it most commonly merely compresses them; sometimes, how- 
ever, the substance of these organs gives way, and the aneurism, 
when it bursts, pours its blood directly into the air-cells ; three re- 
markable cases of which I have already related when treating of 
haemoptysis. Frequently the aneurism compresses the trachea, or 
one of the bronchial trunks, which it flattens and eventually destroys, 
and death ensues by a species of haemoptysis from the rupture of the 
tumour. The same occasionally, but not so frequently happens to 
the oesophagus. Sometimes the aneurism bursts into the pericar- 
dium; two cases of this are also quoted, (page 50.) Laennec states 
that he never met with an example of it. The left cavity of the 
pleura, however, is stated to be by far the most frequent situation 
into which the rupture takes place. Laennec quotes a case recorded 
in the Bulletin de la Faculte de Medicine, in which an aneurism of 
the aorta burst into the pulmonary artery. He mentions a case 
where the thoracic duct was compressed and destroyed ; and Corvi- 
sart notices a fatal instance from compression of the superior vena 
cava. I have seen a preparation of aneurism of the abdominal aorta, 
which communicated freely with the vena cava. A preparation is 
in my museum, in which the splanchnic nerve is involved in the aneu- 
rismal tumour. This might account for the violent epigastric pain, 
nausea, and want of appetite, experienced for a series of years by 
the unfortunate man. Aneurisms often destroy a large portion of 
the vertebral column, and there can be no doubt that this destruction 
is the effect of interstitial absorption, not of caries. On the side next 
the vertebras the sac is occasionally completely destroyed, and to use 
the words of Laennec — "the circulating blood is bounded by the 
naked bone :" several instances of which have occurred in my prac- 
tice. 

Aneurisms of the ascending aorta and arch sometimes destroy 
portions of the sternum by their pressure, so as to be at length co- 
vered only by the integuments. Aneurisms of the arch of the aorta 
and of the innominata occasionally project above the sternum. 

There is no complaint more insidious than the one under con- 
sideration ; and many a sufferer has been supposed to be nervous, or 
hypochondriacal and fanciful, who was found, upon dissection, to 
have been affected with ossification of the arteries, or perhaps an 
internal aneurism. Laennec states, that aneurisms of the aorta can- 
not be detected till they show themselves externally, and often the 
first indication of such an affection is the instantaneous death of the 
individual, from the effusion of blood into surrounding parts. The 
symptoms which are sometimes observed, are oppression in the 
chest, dissimilarity of the pulse at the wrists; a loud whizzing or 
rushing at the top of the sternum, perceptible to the hand; obscure 
sound on percussion; rattling in the throat; and dragging down of 
the larynx, when the tumour compresses the trachea. In noticing 



ANEURISM. 505 

these symptoms, he observes: "In the present state of our know- 
ledge, there assuredly exist no certain means of ascertainin? ilie 
existence of this disease, until it shows itself externally. Even 
when the aneurismal tumour has made its way through the parietes 
of the chest, it is not always distinguishable from tumours of a dif- 
ferent kind." And in another place, he distinctly asserts that his 
experience has been insufficient to enable him " to say how far the 
difficulty of diagnosis is likely to be removed by the use of the 
stethoscope." From my limited experience on this subject, it be- 
hoves me to speak with very great diffidence; but the little know- 
ledge I do possess induces me to join M. Bertin who conceives that 
Laennec has undervalued the stethoscope in detecting aneurisms of 
the aorta. Along with the symptoms stated above, it may be men- 
tioned, that persons labouring under diseases of this description are 
generally observed to be very restless and impatient. 

The symptoms must vary considerably according to the size, shape 
and situation of the aneurismal tumour. It may press upon the 
spine, and occasion violent pain in the back, with weakness and 
anomalous nervous affections : — it may press upon a principal bron- 
chial tube, and create dyspnoea, or produce, by pressure, absorption 
of a portion of the lungs, and occasion dyspnoea, cough and even 
haemorrhage. Or it may compress the oesophagus, and produce 
difficulty id swallowing. All these circumstances are well illustrated 
by dried preparations in my museum. 

Strlhoscopic signs. — Strong beatings, synchronous with the pulse; 
in general, a single pulsation is felt, which Laennec terms "simple," 
in contradistinction to the pulsation of the heart, which is double. 
There is a greater impulse and a louder sound, than the mere con- 
traction of the ventricles produces. The single pulsation is generally 
accompanied by the bellows sound, "bruit de souj/lct;" these vary 
in situation, according to the site of the tumour. If the aneurism 
pfMfl upon the air-passages, a peculiar hissing sound will also be 
observed during the act of respiration or speaking. When the 
tumour is large, the chest at that part will sound dull upon percus- 
■soa, and sometimes even the hand, placed upon the part, will 
OODTBy a vibrating sensation to the observer. Still, however, we 
must he cautious in pronouncing a diagnosis, for I have lately seen 
'1 Cases in which, from other causes, one pulsation only was 
I ; which appears to me to be produced by the long-continued 
action of one set of cavities masking the sound of the other. Laennec 
speaks very confidently with respect to one point, which I shall give 
in Ins own words: — " If we find under the sternum, or below the 
right clavicle, the impulse of the circulatory organ isochronous with 
the pulse, and perceptibly greater than that of the ventricles exa- 
mined in the region of the heart, we have reason to suspect dilatation 
of the ascending aorta, or arch — the more so, as it is extremely rare 

lo feel the impulses of the organ of circulation beyond the region of 
the heart, even in cases of the most marked hypertrophy. If this 
phenomenon be found constant, after repeated examinations, we 
may consider the diagnosis as certain." Bertin, in bis work on 

diseases of the heart, slates, that it is not by the pulsations that an 
■13 



506 INFLAMMATION OF VEINS— PHLEBITIS. 

aneurismal tumour is to be detected, but by the great noise which 
accompanies them. 

Treatment. — It is very difficult to give any general directions for 
the treatment of internal aneurism further than that quietness of 
body and mind should be enjoined, together with attention to the 
bowels, and a light and rather dry spare diet. If there be signs of 
plethora, it should be diminished by a moderate bleeding ; if there 
be any local pain, we are to consider whether it will be most advis- 
able to subdue it by the application of leeches, a contra-irritant, 
or by the exhibition of an opiate. From the situation of an aneu- 
rism of the aorta, and its connection with neighbouring parts, we see 
at once how the function of the lungs may be impeded by mechanical 
pressure, independent entirely of the obstruction in the circulation ; 
— how the brain may be affected by impeding the return of blood 
from the head ;— and also how deglutition may be rendered difficult 
and even painful. 

It would appear that we are as yet very much in the dark re- 
specting the functions which the venous system performs, independ- 
ently of returning the blood to the heart; and I feel convinced that 
we have as yet no idea of the large share which inflammation of 
arteries and veins has, and particularly the latter, in different acute 
and chronic diseases. Many surgeons have yet to learn that much 
of the want of success attending surgical operations depends on in* 
flammation of veins, which they too frequently and unnecessarily tie. 

Phlebitis or inflammation of the veins may be produced by ex- 
ternal injuries and surgical operations, even by the slight operation 
of phlebotomy. When saline injection into the veins was first pro- 
posed in cholera, one of the objections that naturally suggested itself, 
was the danger of inducing phlebitis. But it is remarkable that, 
with the exception of two or three slight cases, our fears were proved 
to be groundless, although very considerable liberties were taken 
with the veins. Some forms of rheumatism are nothing more than 
inflammation of veins ; and I believe the great majority of cases 
which are supposed to be inflammation of absorbents, will, if proper- 
ly investigated, prove to be inflammation of veins. The great danger 
appears to depend on the tendency which the inflammation has to 
extend itself towards the heart. 

Symptoms. — Pain in the course of the vein increased on pressure ; 
tension; swelling and inflammation of the cellulur tissue in the 
neighbourhood, which at last involves the whole limb, when the dis- 
ease frequently goes by the name of erysipelas, or diffuse cellular 
inflammation. When the vessel is near the surface, a red line fol- 
lows its course, which feels knotty here and there ; the limb cannot 
be moved without intolerable pain; abscesses frequently form in 
various parts, when the affection is often called phlegmonous erysi- 
pelas. I do not assert that erysipelas is always produced by inflam- 
mation of the venous system, or that inflammation of a vein will 
always extend to the surrounding parts, and produce erysipelas : but 
morbid dissections have convinced me, that these circumstances not 
unfrequently take place. 



PHLEGMASIA DOLENS. 507 

The combination of symptoms denominated fever, takes place, 
and increases with the disease, and it is too often termed typhus; the 
circulation is seriously affected; the head sutlers, and early delirium 
often occurs. 

Inflammation of veins terminates in what is called resolution ; that 
is to say, it is cured without injury to their structure, or to that of 
surrounding parts. Suppuration is said to be the most common re- 
sult of inflammation of veins; but it does not appear to me quite 
certain that pathologists have always been able to discriminate be- 
tween pus and lymphy effusion. Sometimes the vein becomes 
obliterated by the thickening of its coats, either with or without 
adhesions, which form in the canal itself by means of coagulated 
blood, which becomes organized, or of lymph, which is thrown out, 
or, as some allege, of pus, which concretes. When the principal 
trunk of a limb becomes impervious, infiltration into the cellular 
membrane takes place, producing a great enlargement of the ex- 
tremity; and Dr. D. D. Davis, professor of midwifery in the London 
University, has the great merit of being the first who discovered 
this to be the cause of the disease denominated phlegmasia dolens ; 
a discovery which has not only thrown light upon the disease in 
question, but also upon surgical pathology. 

Inflammation of veins sometimes, though rarely, terminates in 
ulceration and gangrene, involving the surrounding soft parts. Os- 
sification of veins is rarely observed; I have seen only one instance 
of it, and that was in the crural vein. The arterial system was very 
much disorganized from the same cause. The preparation is in my 
museum. 

Treatment. — General bleeding is sometimes necessary in this dis- 
ease, but in general the application of leeches, and incisions with the 
knife, are more frequently demanded, to diminish tension. Fomen- 
tations and poultices are required to the part, and the exhibition of 
calomel and opium seems indispensable. This disease, being gene- 
rally considered "surgical;" is not fully treated of here; but I can- 
not lose this opportunity of referring the reader to an excellent 
practical paper mi inflammation of veins, by Dr. Dumbreck, fellow 
of the Royal College of Surgeons of Edinburgh, published in his 
iMagdral dinertatton when he graduated in the year 1S22. 



PHLEGMASIA DOLENS, 

Si/ttifitnms. — Some time after delivery, (within the fourth or fifth 
week,) pain, or some degree of uneasiness, is complained of in the 
hypogastric, lumbar, or inguinal region, with slight fulness at the 

■pper part of the thigh, which soon increase*) and extends down- 
wards, affecting the labium on the same side. The progress of the 

tuniet.Hihin vanes in different cases In some, the enlargement 

lakes place rapidly; thus, 1 bare seen the limb attain nearly' twice 

of the other in the course <»r thirty hours from the time the 

aatsofl lirvt began t" complain. Generally, however, the disease is 

more slow in its march, the swelling increasing to its greatest size 



508 PHLEGMASIA DOLENS. 

in the space of from forty-eight to severity hours. On examining 
the limb, it will be found to be tense, somewhat elastic, white, shin- 
ing and hot, extremely painful, particularly upon pressure or motion. 
The patient is unable to move it herself, and experiences a sensation 
as if it were considerably larger than it actually is. Most frequently 
the disease is confined to one side — both limbs are rarely affected 
at once ; but it sometimes happens that as it declines in one leg it 
attacks the other. 

Occasionally the pain is first felt in the calf of the leg, or the inner 
condyle of the knee, darting upwards and downwards; but in either 
case, the tumefaction goes on rapidly. The pulse is frequent; the 
skin hot ; and the thirst urgent, with great restlessness. The lochial 
discharge cannot be taken into account, as the disease seldom comes 
on till it has disappeared. 

The phenomena above described are frequently preceded by de- 
cided marks of uterine irritation, and often by rigors; indeed, the 
worst form of this complaint is that which succeeds to peritonitis, 
and to symptoms indicating considerable irritation or inflammation of 
the membranes of the brain ; and I have seen three instances in 
which women were attacked with phlegmasia dolens succeeding to 
affections of the brain ; which had been preceded by severe peri- 
tonitis. 

The peculiarities of this disease are, that the limb is hot, white, and 
although swollen, the parts preserve nearly their relative proportions; 
in anasarca, the limb is generally cold ; the swelling is greatest at 
the most depending part ; and it pits on pressure, which does not 
happen in the first stages, at least of phlegmasia dolens. 

The duration of this curious affection is very various, depending 
much upon the constitution of the patient, the severity of the attack, 
and the mode of treatment in the early stage. In bad cases, which 
have been allowed to go on too long without applying the proper 
means, it is tedious and intractable, occupying weeks, and even 
months, leaving the patient, even then, feeble and in a dangerous 
situation. Under such circumstances, the limb will rarely recover its 
former small size, and will be for a long period stiff and powerless. 

It will be found that Mr. White's description of the symptoms 
varies from that of Mr. Brandon Trye, and both somewhat from 
that of Dr. Hull ; and Dr. Dickson states, that the march of the dis- 
ease in the same woman varied in different attacks, which is exactly 
what I have myself noticed. In the 2d vol. of the " London Medi- 
co-Chirurgical Journal," it will be found that Dr. Belcombe mentions 
the case of a lady, the mother of four children, who experienced 
three violent attacks of this disease, after giving birth to the first, 
third and fourth child — her labours having always been easy and 
natural, and her general health good, except a decided tendency to 
constipation. The first attack commenced with pain in the right groin; 
the second commenced with pain in the calf of the left leg; the third 
was the most severe of all, and commenced about four days after 
delivery, again with pain in the right groin, and after violently af- 
fecting that limb, attacked with equal, if not greater severity, the 
left; no lameness or enlargement followed, but there was a tendency 



PHLEGMASIA DOLENS. 509 

to swell in the evening, and a feeling of stiffness upon the least ex- 
ertion. 

Phlegmasia dolens occurs also during pregnancy. In the same 
volume of the work above quoted, Dr. Dickson mentions having 
seen one case during pregnancy, and relates another, which occurred 
to Mr. Henderson, a surgeon in Bristol. He further states, that he 
is indebted to the same gentleman for an interesting example of 
this affection in the unmarried and unimpregnated female. Puzos 
relates three cases which occurred during pregnancy. In Thomas's 
" Practice of Physic," mention is made of an instance of this affec- 
tion happening in an aged woman. I have myself seen it under all 
these circumstances; and it. now appears, as I shall subsequently 
show, that it is not confined to the female sex. 

Pathological observations. — Some obscure hints are to be found 
in the works of Hippocrates, which would lead us to suppose that he 
had seen the disease. Rodericus a Castro, a Spanish author, makes 
some pointed remarks in the third book of his work,* respecting 
swellings of the legs after parturition. The celebrated Wiseman no- 
tices a case, in the fifth chapter of the first book of his surgical works. 
Mauriceau, however, is the first author, as far as I know, who has 
given a tolerable account of its symptoms. The twentieth chapter 
of the first part of his works, is entitled, "Of the swelling of the 
limbs and thighs of women recently delivered." Puzos and Leve- 
ret also mention it, and suppose it to be produced by a translation of 
milk, which they imagine to be infiltrated into the limb. Mr. White, 
of Manchester, was of the opinion, that the disease is owing to the 
bursting of the lymphatics, from the pressure of the child's head, and 
the retention of the lymph, in the lymphatic vessels and glands of 
the limb. Mr. Ikandon Trye supposed the disease to be seated in 
the lymphatic glands themselves, which are obstructed by the pres- 
sure of the uterus and its contents. Dr. Hull, who wrote a very 
learned treatise upon this disease, conceives that it "consists in an 
inflammatory affection, producing suddenly a considerable effusion 
of serum and coagulating lymph from the exhalents into the cellular 
membrane of the limb." (P. 204.) He considers that the pyrexia 
proves, beyond all doubt, the existence of a general inflammatory 
diathesis; the excruciating pain, tenderness, heat and swelling of the 
leg, equally evince the presence of topical inflammation; the seat of 
tin: disease he believes to be in the muscles, cellular membrane, and 
inferior surface of the cutis; and in some cases, perhaps, the inflam- 
mation may be communicated from these parts to the large blood- 
Is, nerves, lymphatics and glands. An attempt has been made 
to identify tins disease with diffuse inflammation of the cellular mem- 
brane ; but in the disease I am now describing, there arc no marks 
of inflammation of the cellular sdbSfance, whether subcutaneous or 
intermuscular, or of the musr-nlar fibre itself, and the external aspect 
of the affected part is very different Dr. I). I). Davis, professor of 
midwifery in the London University, to whose ingenuity operative 
midwifery stands so much indebted, being dissatisfied with all the 

• " Dc Uni versa Mulicbrium Morborum." 
43* 



510 PHLEGMASIA DOLENS. 

pathological opinions that had been laid before the profession, set 
about the investigation with a mind unfettered by any particular doc- 
trine ; and so determined was he to be guided by the appearances 
displayed on dissection, that he resolved to employ a distinguished 
anatomist, who was to draw up his own report. The first fatal case 
which occurred in Dr. Davis's practice was that of a poor woman 
in St. Giles's, in the year 1819, and Mr. Laurence was requested to 
conduct the dissection. No distended lymphatics were observed, nor 
diseased lymphatic glands; but the crural vein was found diseased 
and thickened in its coats, and its cavity obliterated by an organized 
coagulum, and a matter which appeared like pus. Dr. Davis made 
public. the result of this dissection in his class-room, and it became 
the subject of discussion at the medical society of St. Bartholomew's 
hospital ; and perhaps it is fortunate for Dr. Davis's fame that that 
discussion took place, as very daring attempts have been made to 
deprive him of the merit which is so justly due to him. Subsequently 
to this period, Dr. Davis and others have had several opportunities 
of examining fatal cases, and in every instance, as far as 1 am aware, 
either the crural or the iliac veins were found affected in a similar 
manner.* After lecturing upon this subject in December, 1S24, the 
late Dr. Dease, surgeon to the forces, who did me the honour of at- 
tending my class, told me that he had produced such a disease in the 
person of a sergeant of an Irish militia regiment, by tying the saphena 
vein to cure a variax. All the phenomena of phlegmasia dolens 
took place ; the inflammation of the vein seemed to extend into the 
abdomen. The disease was subdued by copious depletion, but the 
man had a narrow escape. It would appear that the same circum- 
stance has happened in the hands of Sir Astley Cooper, by tying the 
same vein. A case occurred, in the lower extremity, after amputa- 
tion, in a male patient operated on in the Westminster hospital; 
phlegmasia dolens took place in the other limb, and after death the 
disease was traced from the vein of the stump, which became in- 
flamed soon after the operation. The disease ascended along the 
vessels, so as to affect the iliac portion of it ; after reaching the bifur- 
cation of the vena cava, the inflammation extended down the iliac 
vein on the opposite side, which was found thickened, and contained 
the same kind of plug observed in Dr. Davis's cases.t 

In the present state of our knowledge, I am far from alleging that 
inflammation of the veins is the only cause of this affection ; but I 
conceive that no reasonable mind can reject Dr. Davis's pathology. 

Treatment. — It would appear that Puzos was among the first 
who recommended blood-letting in this disease; and Leveret fol- 
lowed his footsteps ; but topical bleeding was not used until recom- 
mended by Mr. Trye. If the pulse be strong, and the patient robust, 
it may be found advisable to take blood from the arm in considerable 
quantity; but should phlegmasia dolens succeed any other acute 
disorder, which has left the patient much weakened, either by dis- 

* Vide Vol. xii. part 2, Med. Chir. Trans, of London. 

+ The reader is referred to the dissection recorded at pp. 52, 53, of this volume. 
The appearance of the veins is described in a young woman, who survived an at- 
tack of the disease for some years. 



PHLEGMASIA DOLENS. 51 1 

eased action, or the remedies employed to reduce it, the lancet is 
inadmissible. We must then rely upon topical bleeding by leeches, 
purging, fomentations and blisters ; in all cases, large doses of calo- 
mel and opium are necessary. As soon as fulness, with pain in- 
creased on pressure, is observed in the inguinal region, we shall 
have reason to dread an attack of this disease, and therefore must be 
on our guard ; and should there be the least appearance of its becom- 
ing worse or extending, ten, twenty, or thirty leeches should be ap- 
plied over the part atfected, and repeated in increased numbers, again 
and again, if necessary. The great point to be attended to is to 
arrest the disease before the swelling takes palce in the extremity. 
In this way, I think I have been able, during the last ten years, to 
check it several times in its first stage. If not called till the whole 
limb has become swollen, we must have recourse to leeches in such 
numbers as the strength of the patient will admit. Antimony is to 
be used as a contra-stimulant: in all cases it is a powerful means of 
enabling us to save blood. I cannot agree with Dr. Davis respect- 
ing the administration of digitalis, when we have a more powerful 
and certain remedy in antimony. In the latter stages of the disease, 
blisters are to be applied, so as to occupy the lower part of the belly, 
as well as the upper part of the thigh of the patient. I have seen 
good effects, in one case, from the application of ice to the limb in 
the early stage of the disease, but it might prove a dangerous remedy 
after the swelling has taken place. During recovery, frictions and 
bandages will be found very beneficial. 

With respect to the general treatment of inflammation of veins, it 
may be shortly stated, that it must be conducted upon the same prin- 
ciples as recommended in other severe inflammatory complaints. But 
I would strongly urge the free and early administration of calomel 
and opium, which is represented to have been so beneficial in inflam- 
mation of veins in the ordinary state of the system. 



CHAPTER VIII. 
PLETHORA, AND EXSANGUINITY. 



PLETHORA. 



I wish to restrict the term plethora to express an undue quantity 
of blood in the system. Although it can scarcely be ranked as a 
disease, yet it deserves to be treated of in a course of the Principles 
and Practice of Physic, as a powerful predisposing cause of many 
serious affections.* 

Where there is such a redundancy of blood in the system as to 
threaten mischief, some of the following symptoms will be observed: 
— an overpowering sense of heat and fulness; flushed face ; oppres- 
sion in the chest, and more or less difficulty in breathing ; weight at 
the prsecordia; a sense of uneasiness or fulness in the head; a full 
strong pulse ; occasional vertigo ; a difficulty in keeping awake, par- 
ticularly after a hearty meal; disturbed nights, from heat of surface 
and disagreeable dreams; and appearance of debility, which is not 
real but which induces many people to take more food and more 
wine, even when the pulse is full and bounding. The bowels will 
be found to be out of order, and the tongue, in general, loaded. To 
a person so affected, the least accident, as a fright, or exposure to 
cold, or drinking a cold fluid, or eating any thing indigestible, de- 
ranges the balance of the circulation, and simple apoplexy may be 
produced, or accumulation of blood in some other internal organ, 
terminating in inflammation; or the combinations of symptoms deno- 
minated fever, may take place. 

Causes. — In youth, generally speaking, the constitution is pletho- 
ric, the demand for blood being great to meet the wants of the system, 
to supply the means of growth, and the development of the various 
organs and functions of the body. At the age of puberty, the system 
is very active ; and it is sometimes matter of wonder, how quickly 
the various parts of the body take on the appearance of manhood. 
This period, therefore, is well known, even to the vulgar, as a criti- 
cal period of life. 

The plethora necessary to effect all these changes, subsequently 
becomes less and less requisite ; and its continuance is the cause of 
many serious maladies which are known to take place at this age, 

[* See the section on Diseases of the Blood, page 459.] 



EXSANGUINITY. 513 

in the shape of fever, inflammation and consumption. Indolence 
and sedentary habits are also causes of plethora. 

Some people make blood quickly; feed them on the lowest diet; 
but give them liquids, and they will still be plethoric: but there are 
others, who daily feed upon the richest articles of food, and yet can 
never be said to be in that state. 

Treatment. — It is fortunate for mankind that diarrhoea so fre- 
quently takes place, and assists the constitution when struggling for 
her very existence; that profuse perspirations are so easily excited; 
and that the kidneys act occasionally so as to produce an increased 
flow of urine — all of which circumstances tend, in a remarkable man- 
ner, to deplete tbe system. It will be observed, that eruptions of 
various kinds appear on the face, back, breast and shoulders, at the 
age of puberty, acting the part of good contra-irritants, to the relief 
of internal organs ; these eruptions, which are generally of the slow 
suppurating kind, produce considerable local irritation. Sometimes 
I have seen urticaria appear very generally over the surface of the 
body, when the system was to all appearance in great jeopardy. 
Episiaxis, or bleeding from the nose, is known to take place fre- 
quently in plethoric subjects, and is often productive of the greatest 
benefit. 

The buoyancy of spirits, so peculiar to young men, urges them to 
athletic and manly exercises, and does good, not only by strength- 
ening the frame, but also by preventing plethora. In females, the 
menstrual discharge appears to operate in preventing a redundancy 
of blood. 

The consideration of these circumstances leads us at once to the 
proper plan of treatment, not only for the purpose of preventing ple- 
thora, but of reducing it when it does exist, and threatens danger. 
Blood-letting occasionally saves life; but it is very far from being 
necessary in the majority of cases, unless some important organ is 
threatened with inflammation. At first, the bowels should be very 
freely acted upon, and subsequently kept regular, so that the patient 
shall have one or two free evacuations daily. Regular exercise; 
rising ; moderate indulgence al table; avoiding slops ; and sleep- 
ing in a well-aired room, are all points of the greatest consequence. 



EXSANOUINITY. — ANEMIA. 

Tins disease IS characterized by a deadly paleness over the sur- 
face of the body, particularly of the face and lipa The pulse is 
quick and feeble, easily excited, and there are frequently palpitations; 
the appetite is impaired ami fastidious; the bowels are disordered j 
there are languor, general debility and emaciation. 

There is considerable approach to tins affection in chlorosis ; and 

imetiraes produced by the actual loss of blood. This is an 

»n which has been noticed by the older writers, but we are 

not yet acquainted with the pathological condition of the body <»u 

which this bloodless state depends, when it is not occasioned by 

hsBmorrhage. I have seen the affection occur at all ages, and in indi- 



514 EXSANGUINITY. 

viduals of apparently very different habits and occupations. The 
most unsophisticated example of exsanguinity on record, with which 
I am acquainted, is that related by Dr. Combe of Leith.* 

This disease affected a considerable number of workmen, who 
were employed in a coal mine at the village of Anzin, in the imme- 
diate vicinity of Valenciennes, in which neighbourhood I resided 
for upwards of two years, and had frequent opportunities of satis- 
fying myself of the correctness of the statements given in the 9th vol. 
of the "Journal de Medecine," by Professor Halle, of Paris. Although 
the disease attacked the men severely, who were employed in a par- 
ticular mine, yet I observed that a considerable number of others 
were pale and emaciated, and very few of the colliers looked strong 
and ruddy. The pit in which the disease occurred, was one hundred 
and twenty fathoms below ground, excavated in the same manner 
as the others, only from being longer, it admitted fresh air less 
readily; its temperature was 64°, and it exhaled an odour of sulphu- 
retted hydrogen gas, and respiration in it is described to have been 
difficult. The workmen affirmed, that the water which filters across 
the mine, on touching their hands, or the naked parts of their bodies, 
produced blisters and boils. Nevertheless, they had the imprudence 
to use it occasionally for the purpose of allaying thirst. A descrip- 
tion of the symptoms was sent to the school of Medicine in Paris, 
by which it appears, that the disease commenced with violent colics, 
pains in the intestines and stomach, dyspnoea, palpitations, diminution 
of strength, distension of the abdomen, and stools of a black and 
green colour. The patients continued in this state for ten or twelve 
days, or more, when the abdominal pains ceased, but the pulse re- 
mained feeble and contracted ; the skin lost its colour, and became of 
a yellow tinge ; locomotion was performed with difficulty, and accom- 
panied by great fatigue; frequent palpitations caused an extremely 
painful state of anxiety ; the face became swollen, and copious per- 
spiration took place. This state is represented to have continued 
even for more than a year, attended by wasting and emaciation. 
At length, the symptoms recurred with violent headaches ; frequent 
attacks of syncope; intolerance of light and sound; tympanitic dis- 
tension, pain in the belly, and purulent stools ; and death soon closed 
the scene. 

When these details were transmitted to the Society of the School 
of Medicine in Paris, out of fifty attacked with it, three died, and 
none were perfectly cured. Upon an earnest request on the part of 
the Society, four pitmen were sent to Paris, on purpose that the 
phenomena of the disease might be more carefully watched — the 
treatment more efficiently directed — and in case any of the patients 
died, that the appearances on dissection might be minutely recorded. 
Two of these men recovered perfectly, one imperfectly, and one died. 
The following appearances were found on dissection. " The abdo- 
men contained no serous exudation. The intestines, and especially 
the colon, were very much distended; and the fat, both subcutaneous, 
and in the omentum and mesentery, was very yellow. The liver 

* Medico-Chirurg. Trans, of Edinburgh, vol. i. 



EXSANGUINITY. 



515 



was small, and did not project beyond the ribs ; it was soft and plia- 
ble in every part; it was of a pale yellow colour, both externally, 
and in its substance, which was soft and unctuous to the touch. The 
gall-bladder was half full of bile, of a colour like the yolk of an egg ; 
and when analyzed, was found to contain much coagulable albu- 
men. The spleen was small and softer than ordinary ; and the liquid 
which flowed from it, as it generally is, was red, like the dregs of red 
wine. 

The stomach, when opened, was found half full of a liquid co- 
loured like the dregs of wine. The duodenum and the jejunum 
were lined with a mucus of a similar colour: and when that mucus 
was removed, the membrane, both in the stomach and intestines in 
all their extent, appeared white and sound. The matter contained 
in the rectum was thick and figured, and of a greenish brown colour. 
All the other abdominal viscera were sound. 

In the cavity of the thorax, the right lung adhered almost every- 
where to the pleura, and especially on its anterior part, but the left 
lung was almost entirely free. In neither was there any remarkable 
quantity of serosity; both were light, crepitated under the fingers, and 
there was no congestion. They were externally white, and mottled 
with dark blue spots; and on incision, a frothy yellowish serosity 
issued from all points of these substances, but not from any preter- 
natural collection. The heart was of an ordinary size, and its flesh 
as pale as that of muscles which have been washed and macerated. 
Its parieies were soft, and the columnae carnae small. Its structure 
was not at all affected. Not a drop of red blood escaped from any of 
its cavities; but in the left ventricle, a coagulum,as pale as the flesh 
of the heart itself, was observed which contained no perceptible por- 
tion of colouring matter; the pericardium contained no serosity. 

The brain was white, the cineritious substance pale, and little 
distinguished from the medullary substance. Two or three scruples 
of serosity only were found in the posterior part of the left ventricle, 
and the choroid plexus was very pale. 

In the three cavities, all the vessels, both arteries and veins, were 
destitute of coloured blood, and contained only a small quantity of a 
serous liquid. No blood was found in the aorta, as far as its crural 
subdivisions, uur in the axillanes, as far as the brachial subdivision, 
nor in the accompanying veins, nor in the system of the hepatic ves- 
sels, nor in any of the sinuses of the brain. Upon making a deep 
incision into the flesh of the thigh, there flowed out a small quantity 
Of liquid and black blood, but from no other part did any flow. The 
flesh of the muscles which cover the thorax was exceedingly red; 
but that of the extremities not much so. 

With respect to the appearances observed in Dr. Combe's patient, 
it uny be briefly stated that they were similar. 

Treatment. — Mercury has been tried, but the result does not aflord 
uracil hope ol us being pre-eminently useful; and, in some cases, it 

was decidedly injurious, by producing febrile excitement. The most 

bwourite remediei ere itimulant and tonic medicines, with occasional 

Opiates, S/heo required to relieve the griping pains in the bowels, 

together with the employment of gentle laxatives. Professor Halle 



516 EXSANGUINITY. 

speaks highly of chalybeates. I have seen several children, who 
suffered much from the draining of blood after being leeched ; but all 
of them recovered under light nourishing food, ass's milk, and a small 
quantity of brandy three or four times a-day, together with warm 
clothing ; the patients being kept as much as possible in the open air. 
I am induced to believe, from reflecting on many circumstances con- 
nected with cases that fell under my notice in the West Indies, many 
years ago, which were forcibly brought to my recollection when pe- 
rusing Mr. Twining's valuable observations on diseases of the spleen, 
in his work already quoted, that disorders of the spleen may be found 
to produce all the appearances of exsanguinity. I cannot speak with 
much confidence on the subject, but I have found much benefit from 
the use of Mr. Twining's spleen mixture in several cases.* 

[* See section on Diseases of the Blood, p. 459.] 



CHAPTER IX. 
CYANOSIS, OR BLUE SKIN. 



This affection is also known by the term "Morbus Cozruleus." 

Symptoms. — Discoloration of the skin, which is sometimes blue ; 
at others, livid or violet ; the whole surface is in this stale, even the 
mucous membrane lining the mouth. There are cough, palpitation, 
sometimes syncope. In some cases dyspnoea is a constant attendant, 
which is increased by exercise, a loaded stomach, constipation and 
mental emotions, together with the application of cold and damp. 

Pathological opinions. — This disease is usually attributed to a 
communication between the right and left sides of the heart, or lo 
some other malformation of that organ, by which means a consider- 
able portion of venous blood is circulated in the arteries without 
having previously passed through the lungs. The passage of blood 
from the right side of the heart to the left may take place in conse- 
quence of the foramen ovale or ductus arteriosus, continuing per- 
vious after birth, or by a communication between the right and left 
ventricle. 

Dr. (iintrac. Professor of Anatomy and Physiology in the School 
of Medicine, at Bordeaux, published a work on this subject in 1S24,* 
and he has collected the results of fifty-three dissections, of which the 
following is an abstract 

In 22 cases the aorta was found to rise from both ventricles. 

— 93 — ihe/bramen ovale was open. 

— 11 — the ductus arteriosus was open. 

— 1 — a single heart, of one auricle and ventricle. 

— 5 — the ventricular septum was imperfect. 

— 22 — the pulmonary artery was contracted. 

— 5 — the pulmonary artery was obliterated. 

— 1 — tin: aorta was obliterated. 

— 1 — the aorta was seen rising from the right ventricle, the 

pulmonary artery from the left. 

The above table is very interesting in many respects : it proves 

that the di as e upon which the colour of the skin depends, is gene- 
rally congenital, when it either rery soon proves fatal, or perhaps not 

till the child sutlers from teething, or begins to walk alone. But, as 

• Observations ct Rcchcrchcs sur la Cyano.se, ou Maladic Bleuc. 
44 



518 CYANOSIS, OR BLUE SKIN. 

Bertin remarks, many of these lesions have existed without the 
appearance of this affection of the skin. It is well known that a 
disease presenting similar external characters has been produced by 
the action of the nitrate of silver. I have seen two cases in which 
the disease followed the exhibition of this remedy; in both it was 
prescribed by the late Dr. Baillie for the cure of epilepsy, and in 
neither of the subjects were there any symptoms of organic affection 
of the heart. It is probable that in such cases the nitrate of silver 
produces a change either in the condition of the blood, or in that 
tissue which gives the colour to the surface of the negro. Bertin 
supposes that the disease depends upon a retardation of the blood in 
the whole venous system, and not upon the admixture of black and 
red blood, as has been alleged by others. [An elaborate inquiry by 
Dr. Moreton Stille has led him to a similar conclusion ; or, to use his 
own language, no one lesion is entitled to be considered as the ana- 
tomical character of cyanosis; but it may depend simply upon any 
cause which, acting at the centre of the circulation, produces general 
venous congestion.*] 

Treatment. — Should the disease depend upon any of the malfor- 
mations of the heart, already noticed, a cure cannot be expected ; 
but something may be done to mitigate violent symptoms, and pro- 
long life, by avoiding exercise, as well as every other circumstance 
which can tend to hurry the circulation, and quicken respiration. In 
the two cases already quoted, in. which the discoloration of the 
skin was produced by the action of the nitrate of silver, every pos- 
sible remedy was had recourse to, first by Dr. Baillie, and afterwards 
by myself, without success. 

[* American Journ. of Medical Sciences, July, 1844.] " 



PART V. 



DISEASES OF THE NERVOUS SYSTEM. 



CHAPTER I. 

GENERAL REMARKS ON THE DISEASES OF THE 
BRAIN, &c. 



Hitherto adescriptionof the disorganizing effectsof diseased action 
on the matter of which the hody is composed, has more particularly 
occupied our attention ; now, however, a more difficult task has to 
be attempted, as the inquiries here commenced involve the conside- 
ration of the functions of the brain, including the investigation of that 
class of affections commonly, but perhaps erroneously, termed the 
u diseases of the mind." There are great difficulties to be encoun- 
tered at every step; one of these relates to the nature of that which 
is called " nervous energy" and the manner in which it is propa- 
gated and conveyed to the different parts and organs of the body. 
Many important discoveries must be made by anatomists and physi- 
ologists before pathologists can be expected to explain fully and satis- 
factorily the true nature and seat of the numerous and complicated 
diseases of the brain and nervous system. Another obstacle, which 
too often thwarts us in our investigations, proceeds from the speedy 
manner in which the functions of the brain become so much affected 
as to render the sick unable to give a correct account of their feelings 
and symptoms. The first step to improvement is to acknowledge 
OOI ignorance; but in doing so, it must not be supposed that these 
branches of medical science have been allowed to stand neglected. 
On the contrary, there are many able and industrious cultivators id 
:, both at home and abroad, and much substantial advance- 
ment lias been already effected by their investigations. 

"Universa . Irabum scholse mansiones muUas>in cerehro statuit 
rt singulis facultatibus singulas seded assigtiat." So says Lauren- 
i, from the experiments of Rolando, Flonrens, Serres, Magcn- 
Chaiies Bell and others, it would appear to be incontestable, 
that different parts of the brain and spinal marrow perform essen- 
tially different functions. It is, indeed, true, that there is a want of 
complete agreement in the results of the experiments of some, of these 
tished physiologists, and that these discrepancies must be 
I by subsequent experiment before the precise value of the 
statements already laid before the public can be accurately deter- 
mined. In the mean time, however, il must be held that the grand 

and leailm- f.u'l il already proved, that the brain performs BOme 

actions essentially different from those emanating from the ccrc- 

ir 



522 GENERAL REMARKS ON 

bellum; and both of these parts from the medulla oblongata and 
spinal marrow : and that the ganglionic system is, in some measure, 
independent of the brain, and is engaged in performing peculiar 
functions. 

The brain has been divided by those distinguished anatomists and 
physiologists, Gall and Spurzheirn, into a number of organs, which 
they conceive to be separate ganglions; and although I must confess 
that I have had neither time nor opportunity to examine their sys- 
tem with that care and attention which the importance of the sub- 
ject demands, and which might enable me to give a decided opinion 
respecting the truth of all its parts, yet experience and observation 
oblige me to state, that much of their doctrines appears to be true, 
and that science owes a great deal to the labours of the gentlemen 
who have been engaged in phrenological inquiry. 

It would seem that the superiority of man to animals, and of one 
man to another, does not depend on the absolute size of the head, or 
even on the relative size of the brain ; for it has been proved that the 
brain of a sparrow bears as large a proportion to its body as that of 
a man, and that of the canary bird a still larger proportion. Man 
owes his superiority over the rest of the animal creation to a larger 
development of the anterior lobes and hemispheres of the brain, and 
to the number and depth of the convolutions.* One man would 
seem to excel another in intellectual and moral worth, not from the 
absolute size of the head, but from a difference in the proportion of 
certain parts in the cerebral mass. Upon the repeated observation 
of these facts the phrenological doctrines have been founded. 

It appears to be established by experiment that there are nerves 
devoted solely to sensation, and others to muscular motion, while 
there are nerves combining both these properties. 

In a work published by Flourens, in the year 1824,t the results 
are given of a great many experiments performed on the lower ani- 
mals, which prove that different parts of the nervous system perform 
different functions. When the two lobes of the cerebrum were 
simultaneously removed from fowls, deafness and blindness were 
produced; the animals fell into profound torpor; they appeared to 
have lost all sensation ; could neither eat nor drink, except when 
food was put into the throat; but when irritated and roused, they 
could walk, jump or fly. When the experimenter removed one 
lobe of the cerebrum only, the animals became deaf and blind on 
the opposite side of the body; the sensibility was only partially de- 
stroyed, and the lethargy was not so profound. 

When he removed the cerebellum from a number of animals, they 
did not lose their sensibility, neither did they become deaf, blind nor 
comatose. The animals still possessed the power of muscular mo- 
tion, but they were unable to control it. They could not balance 
their bodies ; their movements were tottering, like those of a person 
in a state of inebriation. 

* Magendie first observed a connection between the number and size of the con- 
volutions, and the vigour of the intellectual faculties. 

t Recherches Experimentales sur les Proprietes et les Fonctions du Systeme Ner- 
veux. dans les Animaux Vertebres. 



DISEASES OF THE BRAIN, &c. 523 

In a third set of experiments, he removed the corpora quadri- 
gemina in some of the animals, and total blindness of both eyes, 
with immobility of the iris, were the consequence. When the right 
was removed, blindness of the left eye took place. When the left 
was removed, blindness of the right eye was produced. When the 
corpora quadrigemina were wounded, contraction of the iris and 
weakness of vision occurred on the opposite side. Partial removal 
weakened the action of the iris, and produced partial blindness on 
the opposite side. Deep wounds of the corpora quadrigemina pro- 
duced partial blindness; but as the parts healed, vision was restored. 
The organ of vision seems to be the only part affected by injury or 
removal of the corpora quadrigemina in the lower animals. 

Flonrens next performed a series of experiments to ascertain the 
functions of the medulla oblongata. He found that injuries and 
wounds of this organ produced convulsive movements in the parts 
supplied by nerves issuing from it : and he draws the following con- 
clusions. — 1st. That the lobes of the brain, which neither regulate 
nor excite voluntary motion, are the seat of intellect, volition and 
sensation. 2d. That, if the lobes of the brain or cerebellum are irri- 
tated or wounded, contractions of the muscles never follow; but he 
has proved by experiment, that the spinal marrow is the immediate 
agent of all the muscular movements and contractions ; but it is not 
the seat of volition, nor does it possess the power of regulating the 
muscular action. 3d. That the cerebellum possesses the power of 
regulating the muscular action. 4M. That in the lower animals the 
power of vision depends upon the corpora quadrigemina. 5th. 
That the medulla oblongata is the centre of the involuntary move- 
ments, iilh. Another important result is ascertained, that deep 
wounds may be made into the substance of different organs of the 
brain, and considerable portions removed, without destroying the 
functions of the parts. And further, that complete recovery of their 
functions may take place as the brain heals, after they have been 
for a time partially or totally lost. 

From these and other statements in his work, it will be observed, 
that Flourens believes there arc three distinct phenomena in every 
voluntary motion ; first, volition, which depends on the hemispheres ; 
secondly, co-ordination, or regulation of movement, which depends 
en the cerebellum; and thirdly, irritation, or thai power which ex- 
cites muscular contraction, which depends on the medulla oblongata, 
the medulla spinalis and nerves. He has been led to believe that 
volition, sensation and perception constitute hut one faculty, which 
is a function of the hemispheres of the brain. It may he briefly 
mentioned, that Rolando, from experiments performed previously to 
those of Flourens, came to similar conclusions, but wiih this excep- 
. that while the latter mak< a the cerebellum the regulator of 
voluntary movement, the former considers it the source whence the 
motion pro< 

Flourens next performed experiments on many animals, to ascer- 

i| opium, belladonna and alcohol. Ilocon- 

cludea that opium acts more particularly upon the functions per- 

the !"!■' ! Of the cerebrum ; belladonna On those performed 



524 GENERAL REMARKS ON 

by the corpora quadrigemina; and alcohol on the cerebellum. It 
must be confessed, however, that these experiments are not worthy 
of so much attention as the former. 

It would appear, by a report made to the Academy of Sciences, 
upon the memoir of Flourens, by Portal, Count Berthollet, Pinel, 
Dumeril and Baron Cuvier — that these experiments were performed 
with the greatest care and circumspection ; that Flourens repeated 
the principal ones before these philosophers ; and that they appeared 
correct. It would be difficult to find five men better qualified to 
decide upon a scientific subject. 

In the work published by Professor Serres* in 1826, it is asserted, 
at page 662, of vol. ii., that when an instrument is plunged into the 
lobes of the brain, or into the cerebrum, to a certain depth, severe 
pain and great sensibility are manifested ; although he alleges, that 
the medulla oblongata is the principal seat of sensibility. At page 
664, this author assures us, that disease of the tuber annulare and 
medulla oblongata produces paralysis, equally in the superior as in 
the inferior extremities; whereas disease of the lobes of the cere- 
bellum affects principally the sacral extremities; and disease of the 
lobes of the cerebrum, the superior. He thinks that disease of the 
corpora striata is shown, by effects being produced on the inferior 
extremities ; that of the thalami nervorum oplicorum on the supe- 
rior. He also alleges, at page 687, that disease affecting the radia- 
tions of the thalami nervorum opticorum impedes respiration more 
than that of the radiations of the corpora striata; and that disease 
of both affects the voice, speech and pronunciation. The same 
author also asserts, at page 689, that the lobes of the brain exercise 
a very powerful influence over the voluntary muscles ; and that 
injuries of these lobes are followed by paralysis on opposite sides of 
the body. 

Flourens contends, that when the medulla oblongata is injured, 
convulsions are produced on the same side of the body, which Serres 
thinks deceptive, and asserts that the same law holds good with 
respect to the medulla oblongata as with other parts of the brain, 
viz.: that injuries on one side produce paralysis on the opposite 
side of the body. 

Serres believes, that the cerebellum is the seat of sexual desire; 
and has brought forward facts which appear to show a remarkable 
coincidence between great and long-continued excitement of the 
sexual organs in both sexes, and marks of irritation and disease in 
the lobes of the cerebellum. 

The experiments of Magendie appear, in some respects, to con- 
firm, but in the majority of points to refute, those of the individuals 
already mentioned. He states, that it is not in the brain proper, 
nor in the cerebellum, that the principal seat of sensibility or of the 
special senses is placed. The hemispheres of the brain and cere- 
bellum may be removed in a mammiferous animal, and it will con- 
tinue to experience sensations, odours, sounds and sapid impressions. 
Vision, however, is abolished. Injury of the thalamus opticus is 

* Anatomie Coniparee du Cerveau, dans les duatre Classes des Animaux Verte- 
bres appliquee a la Pathologie et & la Pathologie du Systfcme Nerveux. 



DISEASES OF THE BRAIN, &c. 525 

also followed by loss of vision in the opposite eye : for the exercise 
of sight, "the integrity of the hemispheres, of the thai ami, and per- 
haps of the anterior corpora quadrigemina, and finally, of the fifth 
pair, is necessary."* The parts of the nervous system, he continues, 
which appear to be more particularly destined to motion, are " the 
corpora striata; the optic thalami in the inferior parts; the crura 
cerebri; the pons variolii ; the peduncles of the cerebellum; the 
lateral parts of the medulla oblongata, and the anterior fasciculi of 
the medulla spinalis"! Magendie's experiments on the cerebellum 
and its appendages have been followed by results of the most inte- 
resting nature, more particularly as to the agitated and prominent 
appearance of the eyeballs, and the movements of the animals ; but 
I must refer my readers, for further information, to Dr. Milligan's 
excellent and condensed translation of the work. 

It appears, from the investigations and experiments of Sir Charles 
Bell and Magendie, that the old notion respecting the existence of 
two distinct powers possessed by the nerves, is correct: but the 
former gentleman goes still farther. According to him, each side or 
half of the spinal marrow consists of three columns, each column 
performing peculiar functions. All the nerves which arise from its 
posterior column, are devoted to sensation ; those which arise from its 
anterior column, to muscular contraction; while the middle column 
gives origin to the respiratory nerves. 

The only part of the nervous system which it remains for me to 
notice, is that of the nerve called the great sympathetic, which, to- 
gether with its numerous ganglia, are in communication with the 
brain through the medium of the 5th and 6th pairs of nerves, and 
the spinal marrow through its whole course on each side of the 
spine. It is provided with numerous ganglia, which are for the 
most part deeply seated along the sides of the spine. The nerves of 
this system are smaller, with more of a reddish colour than the 
cerebro-spinal nerves, and are distributed in a peculiar manner, not 
only to organs not under the control of the will, viz.: lungs, heart, 
teh, intestines* bladder, uterus, &c, hut are also arranged in 
plexutefl around the arteries and vena portne. They would seem to 
■ no exquisite degree of sensibility; indeed, Magendie denies 
that th'-y possess it in the least degree. There are dilferent opinions 
respecting the structure and functions of this, as well as other parts 
of the nervous system, and the whole subject stands much in need 
of revision. It would be well for science if an association of phy- 
siologists were formed for the purpose of repeating the experiments 
which have been already made upon this subject.^ I hope there 
are few who will agree to the singular assertion made by Dr. George 

• Ml I siology, by E. Millipan, M. D., p. N -' 

t Ibid., p. 130. 

I- in the Bret edition, and I have lived to Bee Bach a plan 

i Into practice by I Ion. it i- to be boned, however, itiat 

although noiiiing ean be done In Edinburgh, without a practical illustration of a 

which baa long beei loner Medical Bchool, that the 

atloo will di : Into inch groat errore aa happened in 1834, in the 

appointment of men who t name are jmi known oat of ineatreei in 

which ■ 



526 GENERAL REMARKS ON 

Gregory, who, alluding to these experiments, states, "that no reason- 
able hope exists of deriving from them, even if considerably im- 
proved, any practical advantage."* 

For the purpose of preventing frequent repetition hereafter, it is 
essential to lay before the reader, in this introductory chapter, a short 
sketch of the principal symptoms which are supposed to indicate 
disease of the brain. It is also desirable to notice, in this place, the 
nature and causes of those symptoms, which are usually ranked in 
other works as diseases — viz.: headache, vertigo, convulsions, rigidity 
of the extremities, coma, delirium, paralysis, &c. 

1. Headache. — Exclusively considered, headache is, perhaps, less 
frequently a symptom of disease within the head than of disordered 
action of the stomach and bowels. We sometimes meet with^violent 
pains in the head in cases the terminations of which show that there 
has been no degree of inflammation going on ; while, on the other 
hand, instances are not rare of great destruction of parts where head- 
ache has not been a prominent symptom. Headache may be pro- 
duced by determination of blood to the head, and is occasionally 
very much complained of after excessive depletion ; some individuals 
never partake of certain articles of food, without being severely 
afflicted ; and with many, long fasting has also the same tendency. 
The common effects of intoxication, more particularly when pro- 
duced by champagne, are too well known as a cause of headache to 
require being here insisted on. There can be no doubt, that loss of 
balance between the arterial and venous systems in the head, pro- 
duces this symptom. Persons who are frequently afflicted with head- 
aches, when these are preceded by rigors, attended by giddiness and 
drowsiness, and especially when produced by every slight exertion ; 
by exposure to cold during the course of ordinary occupations, en- 
tering a heated apartment, or taking any stimulant, become objects 
of serious attention, and require medical treatment. The most effi- 
cacious plan is to enjoin rest and quietness, to open the bowels, apply 
cold to the head, and to bathe the feet in very warm water. Some 
cases will be relieved by a stimulant, a nourishing meal, or an opiate, 
while others will require general or local depletion. 

2. Vertigo. — This is a more important symptom than the former, 
and is produced by various and opposite causes, viz.: by determina- 
tion of blood to the head, as in inflammation of the brain ; by the 
want of a proper supply of blood in the head, as in haemorrhage, or 
after considerable depletion ; by loss of balance in the circulation 
between the arterial and venous systems ; by extravasation within 
the skull; by ossifications of the arteries of the brain; or by the 
growth of tumours and other disorganizations which may occur 
either on the surface or within the substance of the brain itself. Ver- 
tigo is one of the well-known effects of drunkenness; it is also oc- 
casionally produced by indigestible substances in the stomach and 
bowels — by the motion of a ship, a carriage, or a swing — by looking 
over a precipice, or climbing a ladder— or by running round in a 
circle; and it is rather a curious fact, that vertigo shall take place 

* Practice of Physic, p. 331. 



DISEASES OF THE BRAIN, &c 537 

upon rising out of the recumbent posture after confinement to bed 
only for a day or two. Vertigo is likewise produced by dilatation 
of the cavities of the heart, and disease of the valvular tissue. 

3. Convulsions. — Convulsions sometimes indicate disease of the 
brain. They frequently attend inflammation, and there can be no 
doubt that they occasionally depend on organic lesions. It would 
appear that convulsions are occasionally produced by too much 
blood in the head, and there can be no doubt that they are frequent- 
ly occasioned by too little blood, as after excessive depletion, particu- 
larly when the body is brought into the erect posture. They some- 
times take place from the loss of balance in the cerebral circulation. 
Indigestible substances in the stomach and bowels, and worms, 
together with the excessive use of stimuli, opium, &c, are well- 
known causes of convulsions. But I shall speak more at length 
upon this symptom when treating of epilepsy. 

■». Rigidity of the extremities. The occurrence of this symp- 
tom, combined with paralysis, according to some French authors, is 
never wanting in the stale called ramollissement of the brain. My 
experience is in general confirmatory of their opinion, that it takes 
place in a great majority of such cases; but I shall speak more fully 
on this point when treating of ramollissement of the brain. 

5. Coma. — Coma, or even a tendency to it, is a very alarming symp- 
tom, more so than any of those already mentioned. It may be produced 
by various and even opposite conditions of the brain ; by inflamma- 
tory action, or the growth of tumours; but it is, perhaps, more fre- 
quently occasioned by the state which has been denominated venous 
congestion of the vessels of the brain, than by any other cause; in 
fact, this would appear to be the condition of the brain in simple apo- 
plexy. An opinion, too, generally prevails, that coma always occurs 
in consequence of compression of the brain by effusion ; but this is 
not the fact, as effusion, if it take place very slowly, may exist in 
great quantity without having such an effect. Coma is a frequent 
and a vry alarming symptom in the fevers of this country, and it is 
difficult to discriminate the different states of the brain which give 
rise to tins evidence of disease. He who shall be. able to point out 
a siif: iu<;tli(id of discriminating between the coma produced by the 
advancement of diseased action, which will terminate, if not sub- 
dtied, in disorganizations of the brain, and that occasioned by lost 

DOS ■>!" the circulation, or by other causes capable of being re- 
moved, will confer a lasting boon upon society, and hand down his 
own name to posterity. One classof cases requires depletion, the anti- 
phlogistic regimen and the application of cold to the head ; while 
another sometimes requires the most potent stimulants, and will ho 
injured rather than benefited by the application of cold. 

, r . — Febrile symptoms are produced by inflammation of any 

nor tissue of the body, including, of course, the brainand its mem- 
branes. Vei u must be stated, that inflammation may exist m the 
brain, producing themosl extensive disorganizations, without caus- 
ing those symptoms winch, when combined, are termed fever. For 

example, the pulse, instead of bring Irequent, may be reduced in 
point of Dumber and strength much below the natural standard— to 



528 GENERAL REMARKS ON 

sixty, fifty, or even forty pulsations in the minute. It may be slow 
at the first onset of the "disease, become quick, and continue so for a 
day or two, then sink below the natural standard, and rise again to 
one hundred and forty or even higher, during a subsequent period of 
the disease. During the course of one hour, great variations of the 
pulse may be discovered in affections of the brain ; sometimes it is 
very rapid and intermitting, then slow and irregular; oftentimes be- 
coming so weak as scarcely to be felt, and soon again recovering its 
strength. The character of the pulse must depend upon the consti- 
tution of the patient, as well as upon the treatment pursued ; and I 
am acquainted with no disease in which the pulse becomes so quick 
after considerable depletion. 

A hot skin does not always accompany inflammatory action. 
There can be no doubt that very generally it does, but experience 
proves that the exceptions are numerous. The effects of extensive 
inflammatory action have been frequently discovered in the brain 
after death, in cases where the heat of skin during life had been below 
the natural standard, and where the face was deadly pale rather than 
flushed. 

Restlessness and thirst generally attend inflammatory action ; some- 
times they occur in inflammation of the brain ; but a tendency to 
lethargy, and even to coma, is perhaps more common than restless- 
ness. 

7. Delirium is no doubt a very general consequence of inflamma- 
tion of the brain. But the young practitioner should be aware that 
it does not occur in all cases, and that delirium may exist without 
any inflammatory action ; nay, that delirium may take place from 
the want of sufficient circulation through the vessels of the head, 
particularly when there is a determination of blood to some other 
organ, as in inflammation of the liver, bowels, and even in small 
circumscribed inflammations of the skin and cellular tissue. A slight 
external irritation, such as that produced by a blister, will, in some 
constitutions, occasion temporary delirium. The French practitioners, 
who have devoted much attention to the subject of arachnitis, allege, 
that inflammation of the arachnoid which covers the convexity of the 
hemispheres of the brain, always produces delirium ; but Lallemand, 
who is one of their best writers, states,* that he does not think that 
the arachnoid is the seat of delirium, but that inflammation of the 
arachnoid produces that symptom by affecting the functions of the 
brain in the same manner as inflammation of the pleura will produce 
functional derangement of the lungs, as evinced by the occurrence of 
cough and dyspnoea. 

8. Paralysis. — This is a very frequent result of inflammatory dis- 
eases within the skull, and of tumours and apoplexy. In paralysis 
the muscular or motive powers of the part affected may be weak- 
ened, or entirely destroyed, while sensation may continue unim- 
paired, slightly diminished, or entirely destroyed. In some instances, 
sensation is partially or completely destroyed, while the motive pow- 
ers continue nearly in the natural state. There is another condition 

* In his Second Letter, p. 246. 



DISEASES OF THE BRAIN, &c. 529 

which is worthy of notice — a limb may preserve its powers of motion 
and sensation, but the person may have lost control over muscular 
action ; and 1 have seen instances of this condition in the upper as 
well as in the lower extremities. I have observed it also very often 
in the hind legs of dogs affected with the disease called "the distem- 
per." Paralysis has been very properly divided into three varieties ; 
hemiplegia, paraplegia, and palsy affecting a particular limb or part. 

Hemiplegia sometimes follows an acute affection of the brain, and 
very frequently succeeds to an attack of apoplexy; it does occur, how- 
ever, without being so preceded, when it is said by many to depend 
upon disease of the liver. 

Paraplegia is very frequently produced by disease of the spinal 
marrow; but the best pathologists believe that it may sometimes be 
produced by disease of the brain. Paralysis of one limb may, I be- 
lieve, be produced by disease of its own nerves; I have seen cases of 
paraplegia, and of great muscular debility of the lower extremities, 
occasioned by noxious sexual habits; and it is in these cases where 
local application and nux vomica, or its active principle, strychnia, 
appear to be of so much use. Two instances have fallen under my 
notice, of general debility of the whole of the voluntary muscles with 
paralysis of the superior extremities, which were attended by rigidity 
of the flexor muscles of the fingers, while the intellectual faculties 
remain entire. The disease, in both instances, was produced by the 
action of mercury. The individuals stood in the relation of uncle and 
nephew. 

Paralysis is sometimes sudden in its attack; at other times it is 
slow and insidious. The recovery is sometimes complete ; more fre- 
quently it is only partial, and occasionally the patient remains in the 
same state for life. 

The short sketch now given of these leading symptoms is intended 
to show how difficult it is to understand the diseases of the brain and 
nervous system; and it is to be hoped, will stimulate practitioners to 
be minute in the observation and comparison of phenomena, and 
unwearied in the prosecution of examinations after death. Not- 
withstanding all that has been so ably written on diseases of the 
brim, a great deal of error and ignorance yet prevails on the subject. 
This ia not much to be wondered at, when we consider how slowly 
mankind throw off the effects of long-cherished opinions. Never- 
theless, it is surprising to meet with the most decided affections of 
the brain, which have been allowed to go on to a fatal termination 
Unsuspected, because the symptoms did not tally, either in point of 
number or severity, with those laid down in Cullen's erroneous de- 
finitions. 

It \v;is a favourite speculation of the late Dr. Monro, that the ves- 
sels of the brain cannot contain more blood at one time than another. 
Dr. Abercrombie entertains the same opinion ; and as he ia the most 
recent writer on the pathology of the brain, and, moreover, as the 
point involves important practical results, I shall lay before my 
readers a short examination of his statements ami reasoning.* Dr. 

♦ Pathological ind Pri ties on Disease* of the Brain and the Spinal 

Cord sdedL, 

•15 



5S0 GENERAL REMARKS ON 

Abercrombie thinks he may assume, " that in the ordinary state of 
the parts, no material change can take place in the absolute quantity 
of blood circulating in the vessels of the brain. But the blood circu- 
lating in these vessels must be divided in a certain ratio betwixt the 
arteries and veins of the brain; and it is probable that the healthy 
state of this organ will depend upon the nice adjustment of the cir- 
culation in these two systems." This gives, in my opinion, too arbi- 
trary an influence to the circulation. It is the general belief, that all 
the organs of the body are liable to be affected in their functions, 
sometimes with, at others without any alteration in the circulation ; 
and why should this be denied to the brain ? Dr. Abercrombie thinks 
that the brain is not compressible, "because, (says he,) we may 
safely assert, that it is not compressible by any such force as can be 
conveyed to it from the heart through the carotid and vertebral arte- 
ries." This appears to be rather a hasty assertion; the state of the 
respiration must have a great influence, not only on the quality or 
condition of the blood, which I believe to be a source of many cere- 
bral derangements, but on the quantity of blood in any given organ, 
and more particularly in the brain. In proof of the force with which 
the heart may act on the cerebral circulation, the following case may 
be mentioned. A young lady fell down suddenly and died on the 
spot. On dissection, and aneurism about the size of a hazelnut, 
situated at the origin of the sylvian artery, was found, which had 
been ruptured with such force as to break down the substance of the 
"brain, so that a large quantity of blood found its way into the ven- 
tricles. 

Dr. Abercrombie endeavours to trace the various ways by which, 
in such an organ as the brain, derangements of the circulation may 
be supposed to take place. In a plethoric state of the body, he ad- 
mits that "the arteries going to the head will partake of this general 
condition, and there will be an effort or impulse which tends to pro- 
pel an undue quantity of blood into the arteries of the brain. Though 
no addition to the whole quantity of blood in the brain can actually 
take place, because the vessels of the brain are already full, the con- 
stant impulse will be such as tends to introduce an additional quan- 
tity, and consequently, tends to derange the healthy relation betwixt 
the arterial and venous systems; for any increase of quantity in the 
one system, if such actually took place, would lead to a correspond- 
ing diminution of the quantity in the other. Let us say, for example, 
that the whole blood circulating in the brain is as ten, and that it is 
divided between the arteries and veins as five to five. In the loaded 
state of the system now referred to, we can suppose a case, in which, 
by some sudden impulse from the general circulation, the arteries of 
the brain are, at a particular moment, distended by a quantity as six. 
In any other part of the body this will be followed by similar disten- 
sion of the corresponding veins, and the healthy balance of the circu- 
lation would be speedily restored ; but in the brain the very reverse 
would happen : for as the whole mass of blood must continue at ten, 
if the arteries were distended by a quantity as six,the quantity in 
the veins must be diminished to four ; because the increased capacity 



DISEASES OF THE BRAIN, &c. 531 

in the one system of vessels can only be gained by a corresponding 
diminution of capacity in the other." 

Dr. Abercrombie here asserts, that the quantity of blood in the 
head can undergo no variation; it must be always the same ; but he 
admits that a derangement may take place in its distribution between 
the arteries and veins; the former may sometimes contain too much, 
which necessarily leads to a diminution in the latter, and vice versd. 
Let us follow out Dr. Abercrombie's example, assuming the whole 
blood circulating in the brain to be as ten, and that it is divided be- 
tween the two systems as five to five. Now, whether we begin by 
adding or by diminishing, it allows an addition or diminution to the 
whole quantity of blood in the head, which Dr. Abercrombie believes 
cannot take place. An increase in the arterial system of the head 
cannot take place before a diminution occurs in the veins, nor in the 
veins before a diminution takes place in the arteries; so that if Dr. 
terOmbie's position were correct, no loss of balance could by any 
ility occur in the vessels of the head. 

In tracing the various ways by which derangements of circulation 
may be supposed to take place in the brain, and in following out the 
same line of argument, Dr. Abercrombie states that "if a depression 
has been produced of a portion of bone, so as considerably to en- 
croach upon the cavity of the cranium, or if a coagulum of blood has 
been deposited, so as to occupy a considerable space upon the sur- 
face of tbe brain, the diminution of space thus produced would pro- 
bably affect chiefly or entirely the venous system of the brain. It 
would not diminish the quantity of blood which tends to enter the 
arteries of the head, but it would diminish, in proportion to its extent, 
the capacity of the veins, and thus derange the relations betwixt the 
two systems of vessels, in a different manner from that which has 
been supposed under the former heads, but analogous in its effects 
upon the circulation in the brain." 

ire entitled to ask, why the arteries should have such a re- 
markable exemption? Why should the veins be more affected by 
the pressure than the arteries, nntess the depression or coagulum be 
in the course <>|' id.- longitudinal or lateral sinuses? |f the skull be 
pletely filled during life, and if a piece of bone be depressed or 

-'H urn be deposited, every part of the brain, and all tin; vessels, 
eins, ought to feel it, and not one set of vessels 
alone. 

Prom all ih" facte referred to by Dr. Abercrombie, in his work, 
a last i>> an important practical conclusion, that we can- 
not diminish by treatment the quantity of blood in the head. (br, 
however guardedly Dr. Abercrombie has surrounded himself by 
•us expressions, and more particularly in the second than in 
the tir^t edition, tint seems t<> be his decided opinion. Hut he shall 
. f<»r himself: "Upon the grounds already referred to, there 
i "ii n> believe that we cannot, by our evacuations, diminish, 
ny material degree, the quantity of blood in the head." Bui tin' 

LtionS, be -:i|>p<iv,-s, HTlll be to take oil' the exeessive 

impulse from the circulation. 

imeQte of my lamented friend, the late Dr. Kellie of 



532 GENERAL REMARKS ON 

Leith,* and the mechanism of the skull, show, not as Dr. Abercrom- 
bie supposes, that the quantity of blood in the vessels of the head 
cannot be diminished, but rather, how difficult it is to deplete the 
brain altogether, or so much as to render it cognizable to our senses 
on dissection, even in animals purposely bled to death. Certainly we 
are not entitled to conclude, from any known facts or experiments, 
that the brain must always and in all circumstances contain the same 
quantity of blood. When blood is taken from the arm, the brain 
sooner or later becomes affected, as is shown by the occurrence of 
giddiness, singing in the ears, impaired vision, &c. ; and if the ope- 
ration be still continued, syncope, perhaps convulsions, will follow. 
We then favour the flow of blood to the head, and do all we can to 
impede its return, by placing the body in the horizontal posture, 
allowing the head, in severe cases, even to hang lower than the rest 
of the body. Were Dr. Abercrombie's hypothesis correct, the cir- 
culation in the head, and consequently, the functions of the brain, 
ought not to be materially affected by position; it ought to be nearly 
the same whether the body were supported upon the crown of the 
head, or on the tuberosities of the ischia. In a practical point of view, 
then, both experience and common sense loudly rebel at the bare idea 
of such notions as those entertained by this author; for if it were 
wished to subdue a true inflammatory action in the arterial system 
of the brain, a vein must not on any account be opened, and more 
particularly the jugular, because, by emptying the venous system 
within the skull, or doing any thing which has a tendency to empty 
it, as a matter of course it must follow that the quantum of blood in 
the arteries will be increased in the same ratio, because the vessels of 
the brain must always contain the same quantity;— if there be too 
little in the veins, a proportional accumulation must take place in the 
arteries. Upon the same hypothesis, the converse must also hold 
good, viz.: that when there is great accumulation of blood in the veins 
of the head, acute action ought to be an impossibility; and the most 
effectual method of extinguishing inflammation in the brain would 
be to place ligatures on the jugulars, or by some other means to im- 
pede the return of blood from the head. Cupping, leeching, and the 
application of ice to the head ought also, upon this principle, to be 
injurious rather than beneficial, and the head and shoulders should 
be placed in a depending rather than an elevated position. 

In conducting this important critical examination of Dr. Aber- 
crombie's doctrines, I have not availed myself of the arguments which 
could be fairly drawn from the experiments of Drs. Carson and 
Barry, by which it would appear that the heart exerts a sucking, as 
well as a propelling power, and according to which Dr. Abercrombie 
would have still greater difficulties to contend with. Neither have I 
taken advantage of certain anatomical facts respecting the cavities in 
the brain — the free communication between the ventricles of the brain 
and the bony canal which contains the spinal marrow nor of the 
serous fluid which is known to exist in and about the brain and 

* In Dr. Kellie's death, the world has lost an accomplished physician ; and I have 
to regret the loss of an able friend, to whose advice and assistance I had often to 
apply when in difficulty: 



DISEASES OF THE BRAIN, &c. 533 

spinal marrow, and which is found on dissection to vary so much in 
quantity. I have seen many dissections made with a view to ascer- 
tain whether there existed a communication between the ventricles 
of the brain and the spinal marrow. The subjects being placed on the 
face, the slightest pressure made on the surface of one of the hemi- 
spheres, caused a wave of fluid to ascend beneath the arachnoid of 
spinal marrow as high as the 4th rib. Pressure applied on both 
sides of the brain caused the fluid to mount over the convexity of 
the back, and find its way to the inferior part of the spinal canal. 

[Recent pathological investigations have fully confirmed the fact 
already adverted to, that various diseases of the brain are mainly 
owing to or dependent on morbid conditions of the heart. Among 
these is ramollissement; which is often consequent, not as has been 
generally supposed, to excess of blood in the brain, but to a defi- 
ciency of that fluid from disease of the aortic or mitral valves; whence 
the importance of inquiring into the state of this apparatus in all 
chronic cerebral affections.] 



45" 



CHAPTER II. 

INFLAMMATION OF THE BRAIN AND ITS MEMBRANES. 



1. Inflammation of the membranes of the brain as the disease 
occurs in adults.* — It must be carefully kept in recollection, that in 
all inflammations there may be not only several degrees of the dis- 
eased action, as the acute, subacute, and chronic, but there may 
also be a congestive variety, giving various shades of symptoms. 
The extent and duration of the disease, the age, sex and constitu- 
tion of the patient, must also necessarily give to the symptoms a 
wide range of character. Hence, a person who has enjoyed robust 
health up to the period of an attack of inflammation of the mem- 
branes of the brain, will generally be affected in a different manner 
from another who, for months before, had been daily losing blood in 
consequence of haemorrhage from the nose, the uterus or the bowels. 
Inflammation of the membranes of the brain may also be compli- 
cated with diseases of the lungs, heart, kidneys, or some other 
organ, producing endless modifications: therefore it is impossible to 
convey a correct notion of a disease, by means of a definition con- 
taining an enumeration of a few of the symptoms. 

Cullen has classed all the acute, subacute, and chronic diseases of 
the brain and its membranes under one head, which he has termed 
phrenitis; and the following is his definition : 

u Pyrexia vehemens; dolor capitis; rubor faciei et oculorum; 
lucis et sofias intolerantia; pervigilium: delirium fer ox, vel typho- 
mania." 

This definition will neither suit inflammation of the membranes 
of the brain nor of its substance. It represents a case of very rare 
occurrence, indeed, and one which is therefore an exception to the 
rule. Those who have studied nature, will join me in stating, that 
we rarely, if ever, see the combination of symptoms as above de- 
scribed ; and that a patient may show them all, without the existence 
of inflammatory action. On the other hand, we often meet with 

* Under this head, I shall treat of inflammation of the arachnoid and pia mater; 
because there are no diagnostic symptoms by which we can distinguish inflamma- 
tion of the one membrane from that of the other; but as this distinction is interest- 
ing in the present state of our knowledge with reference to morbid anatomy only, I 
shall defer for the present the further consideration of the subject. I believe that all 
pathologists, especially the French, have attributed too many of the phenomena of 
inflammation of the membranes to the arachnoid, and have overlooked the influence 
of diseased action in the pia mater. 



INFLAMMATION OF THE BRAIN. 535 

inflammations within the skull without symptoms of fever, the face 
being decidedly pale, instead of red: and the pain of head is not 
always a prominent feature of the disease. 

Vogel had probably similar views in his mind when he declared 
that "all the acknowledged symptoms of inflammation of the brain 
are equivocal, not only as to a distinction of one morbid part from 
another, but as indications of inflammation in any part." 

Phenomena of inflammation of the membranes of the brain. 
— 1. This disease sometimes attacks a patient in the following man- 
ner: There is a well-marked rigor followed by pyrexia, intense 
headache, redness of face and eyes, intolerance of light and sound, 
violent delirium, pulse at first considerably above 100. In a day or 
two coma steals on the patient, followed by partial or general con- 
vulsions, terminating in death. This, as has been already hinted, is 
the rarest case to be seen in practice; and it is unaccountable to me 
how Cullen should have been led, in drawing out a description of 
the disease, to choose it as his model. 

ises are sometimes met with, in which the first prominent 
symptom is convulsions ; but upon making minute inquiry we shall 
generally find that the patient had been for some days out of his 
usual state of health; that he appeared drowsy, and rather inactive. 
There may be only one severe convulsion followed by paralysis, 
coma and death; or there maybe repeated convulsions for days, 
with intervals of sense, till the fatal termination, which is generally 
preceded by paralysis and coma. 

3. At other times the disease comes on with severe headache ; 
violent terror producing loud and long screaming, attended with 
considerable disturbance in the intellectual functions, so that the 
patient can scarcely give any account of his sensations ; and coma 
soon makes its appearance. 

4. Occasionally a patient complains, for perhaps a week, of slight 
feverish symptoms, and tinnitus auriuin, but does not suffer much 
from headache; nor is he observed to have more intolerance of light 
or sound than most patients labouring under fever, in which the brain 

I i irly til' 'ted. lie may complain most of giddiness, and 
hi,' of freight OB the crown of his head; his bowels are ob- 
served to resist the action of laxative medicine much more than 
usual; his pulse may be about 100, without any characters indicat- 
ing a serious affection : the heat of skin may be somewhat increased 
at night At length restlessness gives way to what is thought to be 
drowsiness; the patient docs not answer readily when spoken to, 
which is attributed to deafness; and as this is neither an uncommon 
nor a bad symptom in fefer, it is not much regarded, particularly as, 

:i roused, the patient appears quite sensible, and will take any 
thing which is ottered him. Bttt, at last} the coma becomes pro- 
found, the pupils dilated; he will sometimes Luind his teeth; squint- 
ing will ix: observed, with partial or total blindness; paralysis of one 

of the body sometimes follows; and the patient will gradually 
sink after repeated convulsions, which in most cases arc m the. fust 
instance general, bnt by degrees become more partial, till at last they 
only affect the muscles of the face, and some of those connected with 



536 INFLAMMATION OF THE BRAIN. 

respiration. Occasionally, however, the convulsions are partial from 
the first, affecting the muscles of one superior extremity; perhaps 
only some of the muscles, in which case the hand will probably be 
found to be twisted during the paroxysm. 

A fifth form occurs without much fever, but with some degree of 
headache, intolerance of light and sound and considerable giddiness. 
The patient may complain very much of nausea and pain in the sto- 
mach, which being the most prominent symptoms, together with 
constipation, the disease may be attributed to disorder of the digestive 
organs. Vomiting sometimes takes place, and becomes intractable ; 
every thing taken into the stomach being quickly rejected. The 
cerebral disease goes on advancing, but in such a manner as to 
avoid notice, till at last the patient becomes drowsy and comatose, 
or convulsions appear, and death sooner or later follows. 

6. Another form under which the disease advances, is : a patient, 
after being affected with some acute disease for two or three weeks, 
during which he may have been bled and otherwise properly treated, 
the original disease appearing to be quite subdued, may complain, 
while in a state of collapse, of passing restless nights, being disturbed 
and agitated by frightful dreams. His strength suddenly becomes 
increased so as to require restraint to keep him in bed ; his pulse is 
weak, perhaps quick, so weak and quick as scarcely to be counted ; 
the extremities are cold, and cannot, by the most assiduous attention, 
be kept warm ; one or both cheeks present a flush, the size of a shil- 
ling, the rest of the face being deadly pale. The raving is constant. 
There may be subsultus iendinum; picking or twisting the bed- 
clothes, or one or both hands may constantly be in motion, wiping 
the angles of the mouth and eyes, or engaged as if drawing hairs, 
either from the fingers of the opposite hand, or from some parts of the 
face. The tongue, as in the progress of most of these cases, becomes 
parched and brown ; paralysis takes place, with convulsions or coma; 
and as death approaches, respiration becomes difficult, and the pulse 
gradually weaker. 

7. A person may complain of passing restless and uneasy nights; 
he cannot lie long in one posture. When about to fall asleep, he is 
annoyed by some unpleasant thought or frightful dream ; the feet, 
perhaps cold when he went to bed, become very hot ; and he has 
some uneasiness in his head. Towards morning, a slight relieving 
perspiration takes place; he sleeps a little; and awakes with some 
degree of headache, which is attributed to bile, or to the bad position 
of his pillow. His urine may be very scanty and high-coloured ; the 
mouth clammy and the tongue foul ; but after being washed and 
dressed, and taking his breakfast, he feels better, and proceeds to 
attend to his business. During the course of the day, he is weak, 
and experiences a difficulty in applying his mind to the affairs which 
usually occupy him. Every thing he does costs him a struggle ; his 
feet are cold; he feels chilly, and every exposure produces a ten- 
dency to rigor. He is observed to be impatient and irritable, even 
about trifles; and he longs for the hour when his business is to ter- 
minate ; but he retires from it with increasing headache. When he 
goes home, his family attribute his complaints to cold, or to over- 



INFLAMMATION OF THE BRAIN. 537 

exertion, or to weakness, and he is pressed to take nourishment, and 
even wine or spirits and water. These symptoms may be relieved 
or may continue, the patient getting better and worse for many days, 
till at last symptoms of a more urgent nature take place, which une- 
quivocally announce the progress of some serious disease; and when 
a physician is sent for, he finds symptoms denoting a very dangerous 
affection of the brain, or a complicated case which suits his notion 
of typhus fever. The case may be now beyond the reach of reme- 
dies, and coma soon becomes profound. 

In the general remarks, it has been observed how very variable 
is the pulse in diseases of the brain, even in the course of the same 
day. The same remarks are peculiarly applicable to inflammation 
of the membranes of the brain. The pulse may be quick — 140, 150, 
or 160, and weak, for in general, when the pulse is so very rapid, it 
is also very weak ; or it may be above 100, and rather strong; it 
may be at the natural standard, or a little above it, and either strong 
or weak ; or it may be much below 70, very strong, or only of the 
proper strength; and under all these conditions, the pulse maybe 
irregular, intermitting, and varying very much in strength. Upon 
the whole, a very slow or a very quick pulse indicates danger; per- 
haps the former is a more dangerous symptom than the latter, as a 
pulse often becomes very quick in irritable constitutions under the 
application of the usual remedies employed for the cure of inflam- 
mation. 

The observations already made in the general remarks respecting 
the heat of the skin, and the other symptoms usually denominated 
febrile, equally apply to this part of the subject, and therefore need 
not be repeated. 

From a careful examination of the eyes and general expression of 
the countenance, the experienced physician gathers much assistance 
in forming an opinion whether the brain is or is not affected. The 
pupils, in the first stage, are generally found more or less contracted ; 
as tl.. dvances, they often become dilated. One pupil may 

!, while the other is contracted. An immovable pupil, 
whether dilated or contracted] is an important symptom. In almost 
>f inflammation o( the brain, ilie conjunctiva is very vascu- 
lar; in the worst cases, I have observed an angular patch, having 
more or less of a bloodshot appearance, situated near the inner can- 
thus, the apex pointing towards the cornea, the latter part appear- 
ing usually dry and slight muddy. When there is wild delirium, the 
eyes have a very brilliant, animated expression ; when there is coma, 
Of B tendency to it, they look stupid, and are sometimes void of all 
expression. There may be squinting of one or both eyes, or they 
may roll in a frightful manner; may appear as if fixed in their 
sockets ; or one or both may be turned up, giving the expression de- 
nominated pathetic. The eyelids are generally kepi dosed iii the 
commencement of affections <>f the cerebrum, perhaps to avoid the 
light; as the disease goes on, however, one or both are observed to 
be half opened; and there may be partial or total blindness of one 

Or both eyes. This, it may be remarked, is always a more unla- 

vourable symptom than deafness, With respect (<> the expres ion "i 



538 INFLAMMATION OF THE BRAIN. 

countenance, it is sometimes animated, bold and even audacious ; at 
others, the expression is subdued; in some instances, there is a total 
want of animation, with an expression of stupidity, as if the mind 
were not acting at all ; and sometimes there is an appearance ex- 
actly resembling that of a man considerably advanced in a state of 
inebriation. Occasionally the teeth are observed to be clenched, 
approaching to the state of locked jaw. Sometimes there is an 
expression as if the patient were labouring under violent pain; at 
others, it gives the idea of passive suffering. 

The speech is variously affected. Patients sometimes show great 
volubility; at other times they are taciturn. In cases where there 
are marks of considerable oppression of the brain, the words hang, 
as it were, in the mouth ; the patient, forgets the names of his nearest 
relatives even before he is observed to confound one individual with 
another, and he frequently falls asleep before he has half finished 
a sentence. The tongue may be paralyzed partially or completely : 
in general, when the patient shows it, it appears in a tremor; or 
it may be in constant and violent motion, pushing out the cheeks, 
or protruded out of the mouth. It may be either moist and loaded, 
or dry and covered with sordes. 

Respiration is not necessarily affected in inflammation of the brain 
or membranes ; sometimes, however, it is very much so ; but dis- 
section has yet to reveal upon what lesions this depends. Occa- 
sionally, particularly in young persons, the respiration has a crowing 
sound resembling that in the back draft of hooping-cough, of which 
I shall speak more fully under the head of hydrocephalus. Before a 
convulsive paroxysm the respiration sometimes becomes very much 
hurried, and after it subsides it is so slow as to appear altogether 
suspended. 

Causes of inflammatioyi of the membranes of the brain. — Ex- 
perience teaches us that some individuals, from peculiarity of consti- 
tution, or from hereditary conformation, are more liable to inflam- 
mation of particular organs than others. Whatever cause disturbs 
the balance of the circulation between the venous and arterial sys- 
tems may cause inflammation of the brain and its membranes. In 
the fevers which prevail in this country, and which are called ty- 
phoid, there are symptoms decidedly indicating disease of the brain 
from venous congestion ; and it is a nice matter to discriminate be- 
tween a case purely of this nature and one of inflammation ; and 
still more difficult if the two are united. In the one case, stimulants 
may be used with advantage, and in the other, they may do irrepa- 
rable injury. Cold; fright; external injury; suppression of any of 
the exertions ; the sudden disappearance of an old discharge or erup- 
tion, or the healing of an old ulcer ; exposure to a vertical sun with 
the head uncovered, are all causes of inflammation of the brain. But 
constipation of the bowels in a plethoric habit, in addition to some 
of the causes just enumerated, most frequently, 1 believe, occasions 
this disease. Infants are more liable to inflammation of the mem- 
branes of the brain than adults, particularly during the period of 
dentition. This appears to be owing to determination of blood to- 
wards the head, caused by the irritation of the gums. Although 



INFLAMMATION OF THE BRAIN. 539 

men are more frequently attacked than women, yet it is a mistake 
to suppose that thinking men are more liable than others to diseases 
of the brain. It requires something more than the continued exer- 
cise of thought and ardent study; there must be conjoined long-con- 
tinued anxiety of mind, high living, abuse of stimulants, want of 
exercise, cold feet, or inattention to the bowels. All these circum- 
stances predispose to this affection. 

Appearances on dissection. — A person may die in the first stage 
of inflammation of the brain, when the balance of the circulation in 
the vessels of the head is disturbed; and the patient is said to owe 
his death to simple apoplexy. On dissection, the only diseased ap- 
pearances discovered, will be considerable engorgement of the cere- 
bral vessels, with more or less effusion of limpid serum. In inflam- 
matory affections of the brain, we must not always expect to meet 
with effusion, because the patient may die before this result has 
taken place, and death may be owing to what is called the shock of 
the disease, or thai produced by the remedies. 

We sometimes meet with considerable venous engorgement, not 
only of the great sinuses, but of the trunks of the veins running into 
them, and very small vessels containing red blood will be seen arbo- 
rescing with each other in every direction. In many decidedly con- 
gestive cases, I have seen the carotid and vertebral arteries distended 
with dark-coloured blood; occasionally ecchymosed spots are dis- 
covered here and there on the surface of the brain. 

Pure arachnitis must be a rare disease. The arachnoid, in a state 
of health, is not a very vascular membrane ; at least its vessels do 
not convey red blood. In my whole experience. I have not met 
with above six cases of inflammation of the arachnoid membrane. 
In ninety-five cases out of the hundred, the effusion is situated, not 
on the serous surface of the arachnoid, but between it and the pia 
mater. In general, if the least effusion be discovered between the 
membranes of the brain and in the ventricles, it is noted down with- 
out farther examination as the result of inflammation ; but I believe 
there fluid between the two membranes in a state of 

health. Tip; same remark equally applies to the ventricles; besides 
which, it must be recollected that venous congestion, or any other 
lending to impede the circulation in the veins, will speedily 
give rise to a great increase of the quantity of fluid in the brain; 
and this is what Cullen and others have called serous apoplexy. If, 
however, there have been febrile symptoms during Ufa, and a con- 
siderable effusion found after death, and particularly if conjoined 
with vascularity, tin' appearances may be attributed to inflammatory 

action. This is rendered more sertain it" the sffusion look turbid, or 

mi flakes of COagulable lymph; il the convolutions of the brain 

be glued together by lymph, extending either from convolution to 
convolution, or dipping down between them; if the arachnoid which 
lines the dura mate? adhere to the proper arachnoid coat ; il the 
arachnoid coal be ulcerated, or capable of being separated from the 
subjacent memjbrane in tolerably Urge flakes, In inflammation oi 
the membranes of the brain, portions of the cerebral mass arc occa- 
sionally found to adhere very firmly to the surface of the /;/</ muter. 



540 INFLAMMATION OF THE BRAIN. 

such portions appearing softer and of a redder colour than the rest 
of the brain. There is one appearance of the arachnoid, to which 
my attention was first directed upwards of twenty years ago by my 
lamented friend the late Dr. Gordon, as indicative of deep-seated in- 
flammation. This is a dry, unshining appearance of the membranes 
of the brain ; but I believe it is more frequently observed in inflam- 
mation of the substances of the brain than in that of the membranes. 

The membranes of the brain are sometimes found to be much 
thickened by a deposition of coagulable lymph between them, both 
surfaces exhibiting considerable vascularity. 

There are small white bodies found on the arachnoid membrane 
in the close neighbourhood, and in the course of the longitudinal 
sinus, which are called glandulse Pacchioni. When large clusters 
are discovered, they are sometimes, perhaps erroneously, attributed 
to inflammation. Small granular tubercles are occasionally seen on 
the arachnoid; these generally exist in connection with the same 
kind of degeneration in the lungs. On slicing the hemispheres of 
the brain to reach the lateral ventricles, the brain is observed to pre- 
sent many red points, which, if examined for a few minutes, will be 
seen to yield a little blood, and eventually to become small drops. 
The ventricles are sometimes found greatly distended with a serous 
fluid ; and when much distended, the communications between them 
will be seen much enlarged ; perhaps a part, or the whole of the 
septum lucidum, may be soft, broken down and ragged. Effusion 
is rarely, if ever, seen in one lateral ventricle without being found 
in the other. I should not be inclined to attribute two or three 
drachms of serum in the ventricles to inflammatory action ; and 
should be still less inclined to attribute the death of the patient to the 
efforts of such an effusion, because I believe there is always some 
fluid in these cavities. The lining membrane of the ventricles oc- 
casionally shows a considerable number of red vessels, particularly 
if the disease have been of long continuance; the membrane itself 
may be softened or thickened ; but this appearance shall be more 
particularly spoken of under the head of hydrocephalus. The cho- 
roid plexus consists of a congeries of small blood-vessels connected 
together by a very loose cellular membrane. I have seen large 
flakes of yellow lymph adhering to this plexus, the corpora striata 
and thalami. The plexus is sometimes thickened, granular and 
occasionally vesicular. The vesicles are often mistaken for hydatids; 
but they appear to me to have no resemblance to these bodies, and 
to be nothing more than an effusion of serum into different parts of 
the cellular tissue. I attribute much of the effusion found in the 
ventricles to diseased action of the choroid plexus, as well as to that 
of the membrane lining the ventricles. 

On removing the brain from the skull, considerable vascularity 
will, in general, be discovered in the membranes at the base of the 
brain, and when there is any effusion, it will be found generally 
about the central parts, involving the origin of all the nerves, with 
the exception, perhaps, of the olfactory. The effusion may consist of 
a colourless fluid, but in general it is turbid ; lymph of considerable 
thickness and consistence is very often found extending directly back- 



INFLAMMATION OF THE BRAIN. 541 

wards from the point of decussation of the optic nerves to the termi- 
nation of the medulla oblongata; and there are several preparations 
and drawings in my museum, in which the effusion is in such quan- 
tity, and the membranes so thickened, that the origins of the nerves, 
the circle of Willis, the basilar, and even the vertebral arteries, are 
all conglomerated in one confused mass, and some of the parts, par- 
ticularly the basilar artery, and the vertebrals, are twisted out of 
their natural situation. In some instances, I have seen the lobes of 
the brain adhering by an interposition of lymph. I have also ob- 
served the same appearance in the hemispheres, and, in two or three 
instances, the adhesions were old and extensive— no doubt the result 
of a former inflammatory attack. 

Treatment of inflammatory affections of the brain. — There are 
two difficulties to be encountered in practice. The first is to ascertain 
whether inflammatory action be actually going on in the brain; and 
secondly, if it be going on, whether the disease is not already too far 
advanced to admit of the application of the most potent remedy for 
the cure of acute disease — general blood-letting. The most expe- 
rienced physicians are sometimes at a loss to determine these two 
points. 

The remedies necessary are — bleeding, general and local ; purga- 
tives; antimony; cold applications to the head, and warm to the ex- 
tremities; blisters and antiphlogistic regimen. 

There can be no doubt of the propriety, nay, the necessity of open- 
ing a vein in the arm, and abstracting a sufficient quantity of blood, 
if the inflammatory action be acute, if there be marks of venous 
congestion in the head, and if there are none of the usual signs of 
extensive organic lesions present. Even should these exist, if the 
pulse preserve some degree of strength, if the respiration be natural, 
tin- heat of surface considerable, the tongue not parched, and the 
teeth not covered with sordes, bleeding may be tried. But in all 
<>!' inflammation, of whatever organ, the lancet should be cau- 
tiously used, if used at all, when the tongue is dry and parched, when 
the pulse isexceedingly rapid, and more particularly if it he irregular. 
It appears to me, that bleeding from the arm, in cerebral affections, 
''.vantages over opening the temporal artery, independently alto- 
ler of the disagreeable consequences which sometimes happen 
from the latter operation. By opening a vein in the arm, a very con- 
siderable determination of blood is necessarily produced towards the 
extremity operated upon, and the blood flows more rapidly. The 
right side of the heart itself is, perhaps, more immediately relieved by 
preventing the usual quantity of blood from returning to it, which 
will, iii all probability, favour the return of blood from the head, par- 
ticularly if the shoulders be considerably raised, or if the. patient be 
bled in the erect or half-erect posture. 

lysician, however wise and experienced, can tell what quan- 
tify of blood ought to be taken in any given case. To bleed in a 
quantity much under that which is required to subdue a disease com- 
almost worse practice than not to bleed at all; because the 
patient is robbed Of much Btrength without destroying or decidedly 

16 



542 INFLAMMATION OF THE BRAIN. 

mitigating the diseased action, and thereby the subsequent treatment 
is embarrassed. 

When bleeding a patient late in a disease, and in doubt whether 
the application of this remedy may not do harm, the practitioner 
should be watchful of the expression of the countenance, the state of 
the respiration and the pulse. If the countenance become pale and 
haggard ; if the respiration should be either quicker or slower, or 
more laborious; and if the pulse flag, or become weaker and quicker, 
then we may be certain that general bleeding should not be pushed 
further, and our hopes of safety must depend upon other means. 
Even in the most favourable cases for bleeding, it behoves physicians 
either to use the lancet themselves, or to see the operation properly 
performed. I am persuaded that valuable lives are often lost in acute 
diseases from neglecting these points, and particularly in the class of 
diseases now under consideration. It is of great consequence to 
watch the effects as the operation is going on, and to be particularly 
observant after a large quantity, say 30 or 35 ounces, have been 
abstracted. The finger should then be constantly upon the radial 
artery of the opposite arm, to notice the pulse ; and when in doubt 
about proceeding further, it is by far the wiser plan to tie up the arm, 
reconsider all the features of the case, and, in the course of an hour 
or two, to renew the bleeding or not, according to circumstances. 
But in order to show the success of a bold measure, judiciously em- 
ployed, very late in a bad case, the following short history is quoted. 
A young gentleman, aged ten years, after an attack of scarlatina, 
became dropsical. Every part of the cellular tissue was infiltrated ; 
even the scrotum was enormously distended. All the usual remedies 
were employed, except venesection; and I was induced to avoid 
taking blood, from an idea that the patient was too weak to bear the 
remedy, and because the urine coagulated on the application of heat, 
and contained a very large quantity of albumen, the specific gravity 
being 100S°. One forenoon, when under the action of mercury, he 
appeared to labour under nervous symptoms. Smart laxatives were 
ordered; but, in a few hours afterwards, violent tonic convulsions 
took place. My friend Dr. Lewins, of Leith, was sent for ; he opened 
a vein, and bled till relief was obtained. I weighed the blood next 
day, and found that two pounds avoirdupois had been abstracted. 
The boy had no return of the convulsions, the dropsical effusion 
diminished daily, and from that time his recovery went on rapidly. 

I have endeavoured to impress upon my youthful readers the 
necessity of perfect devotion to the exercise of their profession ; and 
that they will be successful in the means they employ for the cure 
and alleviation of diseases, exactly in proportion to the attention they 
pay to their patients. In inflammatory diseases of the viscera, and 
more especially of the viscus now under consideration, an hour's 
delay in the application of an important remedy may cost a patient 
his life; the visits of practitioners should, therefore, be frequent, and 
I would not allow a longer interval to take place between the visits 
than two or three hours. 

Leeches to the temples in considerable numbers are very service- 
able; but the bleeding should not be allowed to go on long if the 



INFLAMMATION OF THE BRAIN. 543 

patient be much reduced. Warm water should not be used ; and 
before the application of the leeches, it will be highly proper to have 
the head shaved. 

Sufficiently powerful purgatives must be used. This is almost 
the only class of diseases in which drastic medicines should be ad- 
ministered, because the bowels are not only difficult to be moved, 
but experience has taught us, that considerable advantage is gained, 
not only by the evacuations, but by keeping up a constant irritation 
along the whole alimentary canal. I am in the habit of giving, in 
very severe cases, large and repeated doses of calomel or croton oil, 
or both conjoined. Three or four scruples of calomel may be ad- 
ministered in divided doses to patients, in such circumstances, without 
producing ptyalism. Should a sore mouth take place, it may be 
regarded as a very slight evil if the patient's life be saved. My rea- 
son for giving calomel in cases of inflammation of the brain is sim- 
ply this: many eminent practical men have written so strongly in 
its favour, that I do not think myself justifiable in withholding it, 
although I place less confidence in its action than many others. But 
in no case do I relax in the employment of other, and, as I think, 
more potent remedies. The doses of laxatives should be repeated 
at intervals of three or four hours; and many cases, which appear to 
be hopeless, and too far advanced in their progress to admit of de- 
pletion, have recovered under their free and constant use. But care 
must be taken that the purging be not continued too long. In pro- 
portion as the disease gives way, the doses are to be diminished, and 
the intervals between their administration lengthened. 

The application of cold to the head is a most important part of 
the treatment, and the physician should see that the remedy is pro- 
perly applied. It has been already mentioned, that the head should 
be shaved before leeches are put on ; the mere removal of the hair 
will sometimes produce a considerable change upon the temperature 
of the bead, and perhaps nothing further may be necessary: hut if 
otherwfse, iced water may 1": applied. A very good plan, and one 
which sriv< M 1 •_'!•■• -it deal of trouble, is to put pounded ice or snow, 
mixed with salt, into a large ox/a bladder, till u is abont half filled, 
and use as a pillow. A small bladder filled in the same manner may 
be laid across the crown of the head; a cloth dipped in ice water 
may be placed over the forehead, It these means eanuot he obtained, 
the best plan ia 10 bring the head over the edge of the bed, keeping 
it at the same time elevated, and to pour a small stream of cold 
Water out of a jug or lea-kettle upon the head for five or six minutes 
at a time, taking care to have a basin properly placed underneath, to 
avoid vretting the bed or the floor. I have aeen patients roused out 
of deep coma, and violent delirinm subdued, by cold properly ap- 
plied to the head, when bleeding had been unsuccessful. At the 
same tunc, ire are to be careful not to continue the cold application 
rot too great a length of time, particularly after the patient's strength 
has been much exhausted, either by the long continuance of the dis- 
. 01 the application of the more important antiphlogistic means, 
It is of rery great importance to support the heat ot the extremities, 
and more particularly in severe cases, which is to be done by frictions, 



544 INFLAMMATION OF THE BRAIN. 

hot fomentations, heated bricks, small flannel bags filled with hot 
sand, or bottles filled with boiling water. 

Antimony, used in small doses as a contra-stimulant, is a power- 
ful remedy in controlling the circulation after bleeding. It is a reme- 
dy which is of great assistance during recovery, and may be given 
from time to time when the patient's appetite is likely to be too much 
indulged, or when he is disposed to be too loquacious. 

I beg to enter my strongest protest against the application of blis- 
ters to the head, or even to the upper part of the neck, in the acute 
stage of inflammation of the brain. They ought to be applied to the 
lower extremities. I urge this recommendation from the result of 
long and attentive observation ; and independently of the disputed 
theory, as to whether the vessels of the head can contain more blood 
at one time than at another. Mustard poultices may be applied to 
the feet. That these remedies may fail, however, and that advan- 
tage may be derived from more powerful means, the following case 
will strongly illustrate: 

Cornelius Hervey was attacked with fever in the beginning of 
winter, 1823. In the course of the disease, he required several gene- 
ral and local bleedings, for the removal of slight local inflammations. 
On the 21st day of the fever, when perfectly sensible, and being in 
a state of very great weakness,he told me he had passed a confused, 
restless night, and that he had had some headache, which he attribu- 
ted to repeated errors of diet, and having overloaded his stomach. 
He was relieved by the exhibition of laxative medicines. On the 
23d day, when he was reduced to a state of great debility, he be- 
came quite delirious, and so furious, that it required two men to hold 
him down in bed. The extremities were cold ; pulse weak at the 
wrist, of thready smallness, and beating 160 in the minute; his head 
was hot, and there was a small flushed spot upon each cheek. During 
the two following days, four leeches were applied to the head, and 
afterwards ten, without any mitigation of the symptoms, and he was 
thought to be too weak to bear any further loss of blood. Ice was 
assiduously applied to the head from the commencement; hot fomen- 
tations to the legs; sinapisms to the feet ; and hot bricks were placed 
round the extremities. Still his legs and feet were cold; the sina- 
pisms, although frequently renewed, had not produced the least red- 
ness ; the pulse had become more feeble; he raved incessantly; 
there was subsultus tendinum to a great degree ; the tpngue was 
hard, dry, fissured, and of a dark colour. As neither coma, convul- 
sions nor paralysis had taken place, and as the pupils still contracted 
upon the application of light, it was thought that no organic mischief 
had as yet taken place ; and as the usual means had failed to pro- 
duce heat in the extremities, hot spirits of turpentine, both separately 
and conjoined with aqua ammonias, was applied to the legs and feet, 
but without producing the slightest redness. Blisters had been ap- 
plied to each leg and thigh the night before, but they produced no 
effect. As a last resource, a towel was dipped in boiling water, and 
applied to each foot. This measure succeeded in producing a con- 
siderable degree of redness ; but it is remarkable, that there was only 



INFLAMMATION OF THE BRAIN. 545 

one very small vesication, about the size of a sixpence, produced on 
the left instep. 

At the moment of the application of the boiling water, he became 
calm and sensible, looked about him as if he had awakened out of a 
sleep, and knew every person in the room, which he had not done 
for several days, and he complained of great pain in his feet. The 
pulse soon became more distinct, less frequent ; and the tongue 
moist. Blisters were again applied to the thighs. Towards the 
afternoon he became worse, and at night I found him delirious and 
insensible, with subsultus iendinum, a dry tongue, and a small 
quick pulse. The extremities, and particularly the feet, were quite 
cold, although warm fomentations and hot bricks had been alternately 
applied, and although the scalded feet were dressed frequently with 
hot spirit of turpentine to keep up the action which had been excited 
in these parts. The blisters which had been renewed on the thighs 
had not risen. Boiling water was again applied to both legs from 
the knees to the ankles. The relief was as instantaneous and decided 
as had been produced by the same means in the morning, but it was 
permanent, and from this time his recovery went on without a bad 
symptom. A superficial slough separated from each leg in the 
course often days, and there was some constitutional irritation pro- 
duced during the course of that process; but the ulcerations healed 
kindly. He was for several months very lame, not from the imme- 
diate efTects of the ulcerations, but from the contraction of the flexor 
muscles of the leg, which inconvenience arose from the bent position 
in which he kept his limbs during his illness, but he gradually re- 
covered the free use of them; and the last accounts I heard six years 
afterwards informed me that he was in the enjoyment of perfect 
health and strength, and able to earn a livelihood for his family by 
manual labour. 

To conclude what I have here to say of the treatment of inflam- 
matory affections of the brain, it is necessary to mention that the diet 
should he strictly antiphlogistic for the first few days; it ought chiefly 
to consist of drinks, such as thin gruel and arrow-root; and during 
recovery, great care should be taken to avoid bringing up the patient's 
Strength too suddenly. The utmost quietness is absolutely necessary 
evere diseases; but it is more particularly essential in those of 
the brain; and for a considerable period, patients who have recovered 
from a severe attack of this kind, should be kept in a very tranquil 
state both of mind and body. Application to business must be strictly 
forbidden, sometimes for several months, and great attention must be 
paid to diet, bowels, clothing, and keeping regular hours. 

[mtnediately after the severity of the disease is subdued, and more 
frequently during recovery, opiates are often productive of great 
benefit, by allaying irritation both of body and mind, and producing 
sleep. 

In many cases of intlamtnatioii of the brain, the secretion of urine 

is either suspended or suppressed; but in every case practitioners 

should examine very carefully jntO the state of the bladder, as some- 
times the s e cretion of urine is rather increased m quantity than di- 
ll.' 



546 INFLAMMATION OF THE BRAIN. 

minished, and I have seen much distress occasioned by its retention 
in the bladder. 



INFLAMMATION OF THE SUBSTANCE OF THE BRAIN. 

The profession is much indebted to Lallemand, Rostan, Georget 
and others in France, and to Dr. Abercrombie in this country, for 
many important facts concerning inflammation of the substance of 
the brain, and the peculiar softened condition into which the organ is 
reduced by diseased action. 

Symptoms of inflammation of the substance of the brain. — In- 
flammation of the substance of the brain seldom exists uncomplicated; 
it is often the result of congestion in the vessels of the head, and is 
always marked by loss of balance of the circulation. Like inflam- 
mation of the membranes, there may be different shades between the 
acute and chronic forms; the attack being sometimes sudden, but for 
the most part insidious. The precursory symptoms are generally 
similar to those which precede inflammation of the membranes. 

The functions of the brain are impaired ; the patient complains of 
vertigo or tinnitus aurium; a feeling of weight in the head; head- 
ache; indeed, Dr. Abercrombie describes this last symptom as being 
very severe, and as giving to the disease a peculiar character, but I 
cannot say that this consists with my experience. There are optical 
delusions, strabismus, contraction or dilatation of the pupil ; difficulty 
is sometimes experienced in articulating words ; the patient's temper 
is observed to be much altered and easily irritated; the pulse may 
be quite natural. Through the day, the patient does not appear to 
be very ill, but in the night the symptoms become much aggravated. 
Perhaps no alarm is yet taken, till weakness is observed to affect one 
side of the body, or convulsions take place ; and when a medical man 
arrives, he finds the patient affected with paralysis, and more or less 
coma. 

Inflammation of the substance of the brain sometimes attacks a 
patient more insidiously. He may complain of lumbago and rheu- 
matic pains in the limbs, or may be affected with vomiting or purg- 
ing ; the true disease is, perhaps, not detected till coma is decidedly 
marked. 

Inflammation of the substance of the brain occurs in the progress 
of the simplest as well as the most severe form of fever in this coun- 
try; it may also take place when the body is much weakened by the 
long continuance of hasmorrhage. In fact, this disease occurs under 
circumstances as different as those already so fully described in 
inflammation of the membranes of the brain. 

When the disease is somewhat advanced, there is considerable 
stupor, and more or less insensibility, without violent delirium. The 
power of speech is lost early, perhaps before intelligence is destroyed. 
The pupil still contracts, showing sensibility of the retina. The 
countenance varies a little in appearance; sometimes there is an 
expression of severity with a frowning brow; at others, it looks 
stupid and vacant. The patient is observed to be deaf, and vision 



INFLAMMATION OF THE BRAIN. 547 

imperfect. At length paralysis takes place on one side of the body, 
but the superior extremities are more frequently affected than the 
inferior, and the flexor muscles of the paralyzed limb are in a state of 
morbid contraction. It would appear also that the limb preserves a 
degree of sensibility, for the moment the arm is touched to count the 
pulse, or any attempt is made to extend the forearm, the contraction 
becomes more violent; but towards the fatal termination of the dis- 
ease, it becomes flaccid and insensible. 

Lallemand thinks it important and highly characteristic, that the 
pain and the disease of the brain be on one side of the head, and 
this peculiar affection of the limb on the opposite side of the body. 
Convulsions frequently take place, and during these attacks, the 
muscles of the paralyzed limb are affected. The rigidity of the flexor 
muscles is not always permanent, but takes place occasionally, some- 
times alternating with general convulsions. 

A urinous smell is also said to be characteristic; but this is proba- 
bly a mistake, owing to a neglected state of the bladder, or to a con- 
stant dribbling of urine which soils the bed. Constipation is a very 
general symptom, although occasionally an opposite state of the 
bowels exists. Respiration is not necessarily affected till towards 
the last. The pulse is seldom much altered till towards the termina- 
tion: the French writers say it is never affected till that period, unless 
some other organ is diseased, but this appears to me to be a too arbi- 
trary statement; indeed, the pulse is frequently slower than natural. 
French authors also allege, that when there is violent delirium and 
a quick pulse, inflammation of some other organ or tissue has taken 
place; although Rostan states that delirium sometimes shows itself 
in the first period of ramollissement. The common position of the 
patient is upon the back. 

The characteristic symptoms are, an absence of violent delirium; 
speedy insensibility; paralysis, accompanied by morbid involuntary 
contraction of the flexor muscles; a urinous smell. Cases occasion- 
ally occur in which there is a different train of symptoms, and in 
which paralysis and rigidity do not coexist. Indeed, Lallemand 
observes, that in some cases there is no paralysis of the voluntary 
muscles, in which circumstances, In- alleges that the inflammation 
ilways its seal m parts <>f tin: brain which have no direct com- 
munication with tin; spinal marrow, viz.: the corpus cailosum, the 

sijilum tu< iilum and the fornix. It is alleged, that when the para- 
lysis is general, tin: inflammation occupies the tuber annulare, or is 
so extensive as to occupy a whole hemisphere: so much so, that the 
othei side of the drain becomes greatly compressed by the tumefac- 
tion of ill.' diseased parts. 

An interesting and very fatal affection of the brain and its mem* 

braiies, c< icted with disease of the petrous portion of the temporal 

bone,and a di charge from the ear, has attracted the attention of 
many distinguished medical authors, The disease is frequently very 
slow in its progress : "inn no suspicion of disease in the brain is 
rtained prior to dissection, when considerable portions of us 
sui- ■ be< n found either in a state of softening, orconvertcd 



548 INFLAMMATION OF THE BRAIN. 

into pus; the membranes being partially destroyed, or very much 
inflamed and thickened. 

Acute inflammation of the substance of the brain often terminates 
fatally in seven or eight days, frequently in a shorter period, but is 
sometimes prolonged till the third week. There is no doubt that it 
is a very fatal disease ; but not so deadly, under proper treatment, 
and in persons not too aged, as is generally represented. I have 
seen several recoveries take place in circumstances which were at 
first sight most unpromising; and in five instances in particular, 
where all the characteristics and all the bad symptoms described by 
Lallemand and Rostan, were present. In two of these cases, Dr. 
Kellie was conjoined with me in consultation. In a third, I had the 
able assistance of Dr. Abercrombie. A fourth 1 was requested to 
see by Dr. Moffit, surgeon of the 70th regiment; and a fifth I at- 
tended with my friend Dr. Lewins. 

I shall here subjoin the particulars of the fourth mentioned case: 

J. S., aged 34. His complaints began with nausea and purging, 
which continued for several days, during which time he frequently 
complained of slight headache. On the 5th of August, 1827, after 
appearing to be convalescent, he complained, towards evening, of 
considerable headache and general debility; pulse SO; face rather 
flushed ; tongue white ; pupils dilated. The head was shaved, and 
36 leeches applied; and he took a laxative medicine. In a few hours 
he appeared to be gradually sinking into a state of insensibility; the 
face flushed, and the expression of the countenance anxious; pulse 
S5 ; tongue white. Next morning he was found in a state of coma, 
lying on his back, with general paralysis ; but the flexor muscles of 
both arms were rigidly contracted, the fingers seemed to be in con- 
stant spasmodic action, and his jaws were clenched ; pulse 85, rather 
weak and intermitting. A vein was opened in the arm, and 36 
ounces of blood were abstracted ; a blister was applied between the 
shoulders; cold lotion to the head. 

1th. Passed a disturbed night; no improvement in the symptoms; 
insensibility continues, and the state of the extremities is the same ; 
urine and faeces passed involuntarily; countenance has a severe ex- 
pression ; eyes fixed ; pupils dilated, and he appears to be perfectly 
blind ; pulse S5, and of natural strength. Ice and 30 leeches were 
applied to his head. Vespere; he has derived some benefit from the 
leeches, which bled profusely; the countenance has lost the expres- 
sion described in the morning; he opens his eyes occasionally, and 
takes drink when offered to him; pulse 90, and soft. The applica- 
tion of ice to be continued to the head. 

Sth. Had a better night, and appears rather improved ; the coun- 
tenance has a milder expression ; but the pupils are dilated, the eyes 
fixed, and to all appearance blind; the paralysis of the superior ex- 
tremities, with rigidity of the flexor muscles of the arms, still con- 
tinue, together with the involuntary action of the fingers; the lower 
extremities are still paralyzed, but not rigid ; passes urine and fasces 
involuntarily; pulse 95. Venesection xii oz., and a fresh blister ap- 
plied between the shoulders, the former one not having risen. The 
evening report states, that the symptoms have progressively improved 



INFLAMMATION OF THE BRAIN. 549 

since the bleeding in the morning, and he is so far sensible as to ask 
for drink, which he appears to relish; pupils more natural; tongue 
white; the blister is now beginning to rise. The ice to be continued 
to the head. 

9th. Appears better, and has in part recovered his speech, recol- 
lection and vision; blister rose well. In the evening he was found 
gradually improving; had one stool since the morning, of which he 
gave previous notice. The cold applications omitted. 

10th. Had some good refreshing sleep during the night; counte- 
nance natural; pulse soft, and although quick it is regular; asked for 
food, and got up without assistance to the close stool. From this 
time his improvement went on rapidly. In five or six days he was 
able to sit up in bed for two or three hours at a time; all the func- 
tions were natural; and in a short time he was able to walk about. 
His ultimate recovery was complete and permanent. 

In the case which I saw with Dr. Abercrombie, the appearances 
were fully more unpromising, and the diseased state of the brain of 
longer continuance. For ten days or a fortnight, this patient had 
had symptoms which resembled the regular paroxysm of an inter- 
mittent; and it was supposed he was alfected with that disease. 
During each attack, the functions of the brain were observed by his 
friends to be considerably embarrassed, and coma followed the last. 
In this case there was also remarkable rigidity of the flexor muscles 
of one of the arms, with paralysis of the extremity. The practice 
employed was very active, and although employed late, it was suc- 
nl, but the patient's recovery was more tedious. 

Causes of inflammation of the substance of the brain. — The 

causes of inflammation of the substance of the brain are the same 

as those in inflammation of the membranes, and need not be here 

Mpeated. But it may be mentioned, that the disease is frequently 

produced in the suhstance of the brain around tumours and tubercles 

which may have existed for years, without occasioning much anuoy- 

'.■ nt, till some accidental circumstance rendered them 

urce of irritation to the surrounding parts. This class of cases 

ally terminates fatally. I have a number of drawings and pre- 

tions which show these appearances; and it is strange that Kos- 
t.ui should never have met with a case of this kind; but at page 70 
Of his work, he Says he has DO doubt that such a complication may 

exist. Inflammation of the Bubstance of the brain, terminating in 
ramolli8sement, also Frequently takes place round apoplectic deposi- 
tions, whether small or large. I have seen it round an effusion of 

about lour ounces of Mood; in these cases the symptoms are, m gene- 
ral, rapid in then- progress to a fatal termination. 
Appearance* on dissection. — When the structure destroyed is 
naive, and particularly when Bituated in the central parts of the 

brain, the arachnoid COal Sometimes looks dry, having lost lis usual 

shin. : nee. On making slices of the brain, more particu- 

larly in the neighbourhood of the diseased part, its suhstance will 
show many red points, out of which blood will ooze: the white sub- 
stance of the brain pi omewhal reddish colour; sometimes 



550 INFLAMMATION OF THE BRAIN. 

it is as red as if a penful of red ink were splattered over it ; occa- 
sionally there is a deep mulberry spot of larger or smaller size. 

The central parts of the brain are most frequently the seat of 
ramollissement, viz.: the walls of the lateral ventricles, the septum 
lucidum, and the fornix. These parts are sometimes wholly con- 
verted into a white liquid matter like cream, showing the septum 
lucidum ragged and broken down, with some effusion into the ventri- 
cles. This appearance is sometimes very extensive; at others it is 
confined to the walls of one ventricle, or it affects the septum lucidum 
and the fornix. When the disease is not far advanced, the degree of 
softening is so slight, that it is impossible to determine whether the 
part has been diseased or not; but in this case we are sometimes 
assisted by discovering very considerable redness in the surrounding 
cerebral mass; at other times the softened part is of a red colour, as 
if blood had been mingled with the substance of the brain itself. 
Some suppose that inflammation of the substance of the brain is 
more frequently met with in the white substance than in the cortical. 
Andral thinks not. I have seen it in both, but am disposed to think 
it is more frequent in the white substance. 

Perhaps the white liquefaction, which is most frequently seen in 
the corpus callosum, the septum lucidum and fornix, may be pro- 
duced by a somewhat different cause from the red softening, which 
is most frequently seen, according to my observation, in the corpora 
striata, thalami optici and tuber annulare. 

Pathologists are much divided in opinion as to whether ramollis- 
sement of the brain is or is not the effect of inflammation. Rostan 
admits it is sometimes the effect of inflammation; but asserts that 
more generally it is a peculiar degeneration of the brain, unconnected 
with inflammation, which has its own signs and proper characters. 
He appears to have three reasons for considering that it is not gene- 
rally a product of inflammation : — Is/. In the cases which terminate 
in this softening, the patients have not been affected with the head- 
ache; 2d. Febrile symptoms have not existed; 3d. The colour of the 
substance of the brain often appears not to be in the least changed. 
Rostan's subjects were all old ; he never saw the disease in a very 
young person, and only once in an individual under 30 years of age; 
but in that case there was no dissection. 

Dr. Abercrombie, with a view of reconciling the opposite opinions 
which prevail on this interesting subject, throws it out as a probable 
conjecture, that there may be two causes, each of which may pro- 
duce ramollissement ; the first is inflammation, and takes place in 
young people ; the second is in consequence of a failure of the circu- 
lation depending upon diseases of the arterial system, and this occurs 
in old subjects. He supposes that this degeneration of the brain has 
a close resemblance to mortification in other tissues; but this appears 
to be a forced analogy. The effect, upon all tissues, of inflammation 
in its first stage, is to soften them— at least this is the case with the 
lungs, the liver and the spleen ; and why not with the brain ? 

Sometimes inflammation of the substance of the brain terminates 
in the formation of one or more abscesses ; and we frequently observe 
the same effort of nature to circumscribe and confine pus in the brain, 



INFLAMMATION OF THE BRAIN. 551 

which takes place in other tissues, viz.: the formation of a false mem- 
brane round the diseased part. 

A medical friend lately presented me with a brain, where there 
were innumerable small abscesses resembling so many phlegmons, 
dispersed in every direction through the cerebrum and' cerebellum. 
Some were situated on the surface of the brain and cerebellum con- 
tiguously to the membranes; others in the very centre of its substance. 
Some were in the white, others in the gray portion. 

The pus found in abscesses of the brain resembles the same mat- 
ter found in other tissues of the body ; sometimes it is quite inodo- 
rous; at others very fetid. 1 am not aware that any symptoms have 
been remarked as indicating the formation of pus in the brain, which 
discriminate it from other organic lesions. 

Treatment of inflummat ion of the substance of the brain. — The 
treatment already so fully detailed under inflammation of the mem- 
branes, is equally applicable to inflammation of the substance of the 
brain; but with a view of impressing upon young practitioners the 
danger of delay, the following case and dissection are annexed. 
Their perusal will serve also to show the insidious manner in which 
inflammation of the brain sometimes steals on, concealed by some 
prominent affection in a distant part of the body. No case can better 
exhibit the advantage of active treatment, even when applied late — 
unfortunately too late, in the present instance, to save the life of the 
patient. 

.1. II., aged 30, tall, active, athletic, and of sober habits; for seve- 
ral months complained now and then of severe lumbago, for which 
blisters had been applied with relief. On the 13th July 1S27, he ap- 
plied for medical advice, in consequence of a return of the lumbago, 
which had been very severe for several days; he became gradually 
relieved by confinement to bed, the application of a blister, laxa- 
. and occasional doses of Dover's powder; on the 3d August, 
to all appearance, lie was very much better, but his bowels were 
rather confined. During the whole of that day, however, he became, 
according to the account of the people about him, more and more 
Stupid, without any apparent cause. When .spoken to he replied, 
but always as if abstracted. Pulse natural ; countenance heavy, and 
rather vacant. 

■\th. Makes no complaint; reposes in one posture, on his back; 
appears fatuous; and when spoken to, returns a vague, inconsistent 
answer; articulates indistinctly ; both hands arc in constant motion ; 
pulse natural and soft ; had two stools. Head to be shaved, and 
cold applied ; sixteen leeches to the forehead ; a blister between the 
shoulders. In the evening no alteration; the leeches bled well. 
Pounded ice lias been constantly applied to the head ; pulse 80 and 
regular; tongue while and dry ; skin moist. Passes urine and faces 
involuntarily. 

5th. 1 1 id a had night \ is insensible ; superior and inferior extremi- 
paralyzed j but the il< tor muscles of the arms are rigid, the fore- 
arms bent, that of the right ami more than the left ; jaws clenched; 
but the lower <nie can DC depressed a little by using considerable 
force ; countenance palhd and bedewed with perspiration ; i 



552 INFLAMMATION OF THE BRAIN. 

fixed, pupils dilated and immovable; pulse 86, regular, and of natu- 
ral strength ; has lost the power of deglutition. In the evening, 
no change of symptoms, except that the countenance has assumed a 
severe expression. There is a strong urinous odour, owing to the 
involuntary passage of urine in the bed. He appears, although in- 
sensible, and having lost the power of voluntary motion in all his 
extremities, to feel the impression of cold disagreeable when the bed- 
clothes are drawn down. Venesection ad 28. The bleeding was 
persevered in till the pulse rose from 86 to 100, and became, some- 
what weaker. During the latter part of the operation he appeared 
to awake as if out of a deep sleep, and looked about him ; and soon 
after was able to reply to any question by a sign, although he could 
not speak. 

Gth. Some time after the bleeding last night, he made signs that he 
wished to lie upon the right side, and upon being turned, expressed 
satisfaction ; has since taken his drink occasionally, and put out his 
his tongue when desired ; his countenance is certainly more cheerful, 
and the eyes are sensible to light, but in other respects does not seem 
much improved ; passes stools and urine involuntarily; pulse 130; 
skin moist; tongue white and rather dry. Thirty-six leeches to the 
head, and a large blister to each leg. 

1th. Passed a more composed and comfortable night ; countenance 
more animated ; is able to articulate, but with difficulty, and when 
spoken to, returns an appropriate answer; pulse 150; pupils dilated; 
tongue white and furred; skin moist ; stools and urine still passed in- 
voluntarily. The application of iced water ordered to be persevered 
in. During the course of the day, the symptoms continued to im- 
prove, and in the evening his looks were more lively ; the counte- 
nance had a more natural expression ; had two stools during the day 
and made water, of which he gave warning, and desired to be raised 
upon the night chair. There is still a little rigidity of the flexor 
muscles of the forearms, as well as spasmodic motion of the fingers ; 
and both hands embrace the genital organs; pulse 140; skin moist. 
Had gruel and arrow -root frequently. 

8th. Appears better to-day; has recovered in a considerable degree 
the use of his extremities ; reposes frequently on his side ; gives dis- 
tinct answers, and is better able to articulate than yesterday; coun- 
tenance mild ; pupils less dilated ; tongue moist and less loaded ; 
pulse 150; skin natural; complains now, for the first time, of debility ; 
and ordered to have food at short intervals. At the evening visit 
he appeared to be doing well, but still complained of being weak; 
the pulse 130, and of moderate strength ; bowels moved twice during 
the day; countenance natural and more lively; tongue moist. 

9th. He was found in a weak, depressed and sinking state this 
morning; respiration and deglutition difficult; pulse 160. Wine 
was ordered ad libitum; but he continued to sink, and died a little 
before midnight. 

Examination of the body 30 hours after death. — Slight emacia- 
tion ; countenance composed ; considerable rigidity of the flexor mus- 
cles of the right arm. On removing the calvarium and dura mater, 
the brain appeared full and distended ; a little serosity between the 



HYDROCEPHALUS. 557 

membranes ; ramiform injection of the vessels of the pia mater, 
forming a complete anastomosis over the surface of the hemispheres; 
the whole presented a deep scarlet colour. In the cortical substance 
of the brain, several red spots from numerous little bloody points 
closely aggregated. The brain, in these places, softer than natural, 
and tore readily on separating the membranes from it. Medullary 
substance also presents bleeding points when cut into. 

On the base of the brain the membranes are in a similar state as 
on the hemispheres; several ecchymosed spots on the lateral parts 
of the middle lobes. After removing the membranes in a very care- 
ful manner from all the central parts at the base of the brain, from 
the part anterior to the point of decussation of the optic nerves to the 
commencement of the medulla spinalis, a number of bright red spots 
were observed in different places. On the left tractus nervi optici 
a considerable spot of a bright red colour, found to penetrate through 
its whole depth; also several smaller spots on the opposite side. On 
each side of \he pons varolii, there were similar red marks, but par- 
ticularly one on the right side, of a dark mulberry colour, about the 
size of the thumb nail ; this was examined minutely, and was found 
to extend deeply into the medullary substance, and to be formed by 
an intimate mixture of blood with the cortical and medullary band 
of ihe pons. There was a considerable spot of a similar description 
on the right side of the medulla oblongata. The membrane lining 
the ventricles was very vascular, and the choroid plexus loaded with 
blood. Nothing remarkable in the cerebellum. Spinal marrow not 
examined. 

Thorax. — Strong and general adhesions on both sides between 
the pletira pulmonalis and costalis; particularly firm on the left side. 
Pericardium strongly attached to the diaphragm, and anteriorly so 
firmly united to the heart as to form only one body with it ; the bond 
of union formed by a very dense, almost cartilaginous substance, 
varying in thickness — 111 some places more than one-third of an inch, 
in others only a !'<:\v lines; the pericardium could with great difficulty 
be separated from it. A part of the posterior surface of the heart 
was unattached to the pericardium. 

MttCOUS membrane of the stomach generally, but more especially 
of its great curvature, of a dark brown colour, with numerous vari- 
cose vessels running below it ; in some places there were little patches 
with Btelliform injections of the minute branches ; other patches were 
Of a uniform blackness. Intestinal canal natural. Bladder contained 
about half a pint of urine. 



BTDBOOSFHALUB. 

TBI frequency and fatality of this disease have strongly excited 
the attention of practitioners, with a view to discover its nature and 
sent Two opinions at present divide the profession: according to 
one hydrocephalus it a disease of inflammation j according to ano- 
ther, it is 0110 of debility. My own Opinion is, that it is most fre- 
quently a disease of inflammation; but that sometimes it maybe 
47 



558 HYDROCEPHALUS. 

occasioned by other causes, which shall be mentioned in the proper 
pace. 

There are several forms under which this disease appears. The 
division which I propose to adopt is as follows: 
Acute Hydrocephalus. 
Chronic Hydrocephalus. 
Under the acute form, we meet in practice with numerous vari- 
eties ; and I shall attempt to give a slight sketch of four of the prin- 
cipal. 

1. Attended with severe and striking symptoms, such as fits of 
screaming; grinding the teeth; -hot skin; quick pulse; bold expres- 
sion of countenance ; red face and eyes; convulsions; coma; the 
children dying on the third or fourth day. In such instances, I have 
seen the first stage terminated in twenty-four hours. 

2. With symptoms very mild and insidious, so much so that no 
alarm is taken for several days. The little patients complain, but 
this is attributed to peevishness or to teething, till at length the pa- 
rents become alarmed by the long continuance of the indisposition, 
together with the rapid emaciation which has taken place. 

3. A third set of cases commences with gastric irritation, attended 
either by constipation or diarrhoea. The febrile symptoms are ob- 
served only at night. Medical men are often thrown off their guard, 
their attention being attracted by the more urgent symptoms con- 
nected with the state of the bowels. By and by the child becomes 
quiet when allowed to rest in the horizontal posture ; it grinds the 
teeth occasionally; and although showing signs of some suffering, 
yet it never cries or becomes very fretful unless when raised. The 
moment the head is elevated, great impatience is manifested, and it 
gives vent to loud expressions of pain, which I suppose to be pro- 
duced by headache or giddiness. 

4. Very frequently hydrocephalus occurs during the course of 
other diseases, such as fevers, measles, small-pox, hooping-cough and 
pulmonary affections; and not uncommonly runs through the first 
stage and part of the second before discovery is made of diseased 
action in the brain. Convulsions and coma take place at different 
periods in the course of the disease. The former is sometimes the 
first symptom, and occurs early in the disease, at other times not till 
towards the fatal termination. In other cases, coma takes place be- 
fore the convulsions, and is the first alarming symptom that occurs; 
in fact, the statements already made respecting inflammation of the 
membranes of the brain, and also of its substance, equally apply to 
this particular subject. The description given of the expression of 
countenance, the state of the pupils, the redness or paleness of the 
face, the state of the respiration, the mental faculties, the pulse, skin 
and bowels, all apply with equal force to hydrocephalus. 

Appearances on dissection. — In the most rapid cases, the patients 
are carried off before organic lesion to any extent is produced. Al- 
though the membranes of the brain may display considerable arbo- 
rescent vascularity, still the effusion is in very small quantity — too 
small to account for death. In cases of longer standing, the effusion 
into the ventricles will be in greater quantity ; or thickening of the 



HYDROCEPHALUS. 559 

membranes may be found not only where they cover the hemi- 
spheres, but likewise at the base of the brain, involving all the im- 
portant parts in the centre, from the point of decussation of the optic 
nerves to the commencement of the medulla oblongata. The 
thickening of the membranes is produced by the intermediate depo- 
sition of tenacious lymph. The membranes have been found exten- 
sively ulcerated, and considerable portions of the brain itself in a state 
of ramollissement, in children who have died with all the symptoms 
of hydrocephalus; and in these cases, there is not always any con- 
siderable effusion into the ventricles of the brain. I forbear, at 
present, to allude to other diseased appearances, such as tumours, 
tubercles, disease of the great sinuses, &c, because these more fre- 
quently produce chronic hydrocephalus. 

Pathological remarks. — The chief point of inquiry relates to the 
cause of the effusion. Is it the product of inflammation ? The best 
pathologists of the present day consider it as proceeding, for the most 
part, from inflammatory action of the membranes of the brain ; but 
at the same time there can be no doubt that a serous effusion is 
frequently the consequence of any cause obstructing, or even retard- 
ing the circulation in the head. Thus it is believed to be occasioned 
by venous engorgement ; and dissection affords ample proof that it 
is often owing to obstructions in the great venous channels in the 
head. — Others allege that hydrocephalus is produced by debility. 

This is a pathological question of the utmost practical importance, 
because the remedies will be depletory in a certain stage of the dis- 
ease, according to the one view, and stimulating in all the stages 
according to the other. In order to place the subject in a clear point of 
view, I shall take the liberty of offering a few critical remarks upon 
a work by Professor Monro,* because it is the last published work 
which defends views that I conceive to be erroneous. At page 101, 
Dr. Monro states that, before subscribing to the hypothesis that the 
effusion in hydrocephalus is owing to some degree of inflammatory 
1, « it is necessary to inquire whether this disease usually occurs 
111 persons who are disposed t<» inllanimatory disorders at or near the 
meridian of life, when the human body is most liable to Buffer from 
inflammatory diseases. With regard to the first of these points, it 
!, that hydrocephalus is so rare after puberty, when 
the constitution is most liable to inflammatory disorders, that Culien 
and other writers of eminence have described it as being peculiar 
only to infancy. That the disease is rather to be imputed to i/ehi/ity, 
follows from the well-known fact, that hydrocephalus is frequently a 
disease which may be traced t<> bad nursing, improper food, dentition, 
the sequel of the mosl tedious and debilitating disorders, as hooping- 
cough and Bcarlatina." 

Cullen's authority is a most unlucky our to ([note in the present 
day for the true pathology of any disease, and more particularly oi 

any disease Of the brain. In the work- of this author, there are only 

two pages and seven lines devoted to a detail of die symptoms, 
causes, pathology and treatment Of all the inllanimatory affections 

• Entitled, The Morbid Anal Irain, 1^-7. 



560 HYDROCEPHALUS. 

of the brain and its membranes; and all that he has said respecting 
hydrocephalus is comprised in three lines, in the shape of an erro- 
neous definition ! 

It is a fact, that children, particularly those under two or three 
years of age, are peculiarly liable to inflammation of the brain from 
several causes: — 1. From the wonderful changes which take place 
in the circulation early in life; 2. The large size of the head at that 
period in proportion to the rest of the body; 3. The change the 
brain undergoes in appearance and consistency; 4. The great acti- 
vity of the circulation, and the high state of irritability of the ner- 
vous system at that period of life; 5. Difficult dentition, which per- 
petually excites a determination of blood towards the head. Besides 
these causes, accounting for the frequency of the diseases, something 
must be said respecting its fatality in infants. Children cannot tell 
their feelings, or direct the attention of practitioners to the seat of the 
disease. Their fretfulness and peevishness are too often attributed 
to bad temper, or to the state of the bowels, or to the irritation of the 
gums from the advancement of teeth; and the disease in the brain, 
as has already been shown, often advances in the most insidious 
manner, till convulsions or coma take place : and even the latter 
symptom, although observed in its progress, is too often overlooked 
until the patients become insensible. Bad nursing and improper 
food, upon which Dr. Monro has laid so much stress in support of 
his own views, certainly tend to produce debility; but children badly 
nursed, insufficiently clothed, who are allowed to remain wet, and 
receive improper food into the stomach, are peculiarly liable to in- 
flammation and ulceration of the bowels. They will be far more 
liable than healthy children to irregular determinations of blood, and, 
from want of vigour in the constitution, venous engorgement may 
take place, the vessels of the head may suffer, and effusion may in 
consequence follow ; perhaps subacute inflammatory action may be 
lighted up in the brain. The experienced eye of a careful observer 
will be able, in general, to detect the disease in the brain, although it 
is not announced by symptoms so violent and imposing as Dr. Monro 
seems to expect should be produced if actual inflammation had 
taken place. That venous congestion of the vessels of the head, ter- 
minating in effusion, and that inflammation of the membranes of the 
brain, should sometimes lake place in hooping-cough and scarlatina, 
which Dr. Monro designates as debilitating disorders, will not sur- 
prise any who will study nature, or who will refer to the patholo- 
gical descriptions given of these diseases in their proper places in the 
1st vol. of this work. 

Dr. Monro next asserts, that if hydrocephalus were an inflam- 
matory disease, it ought, like inflammation of the lungs, and other 
inflammatory complaints, to be more prevalent in robust men during 
the period of life when the human frame is most prone to other in- 
flammations. Dr. Monro might have known that the periods of life 
at which inflammatory complaints most frequently occur, are infancy 
and childhood, and that for one inflammatory fever, or inflammation 
of the lungs, or of any other organ, in robust men during the prime 
of life, we meet with at least fifty in early life. 



HYDROCEPHALUS. 561 

Dr. Monro has committed a sad mistake respecting the opinions of 
two distinguished French pathologists. " If it be supposed, (says 
Dr. M.,) that hydrocephalus is always connected with inflammation 
of the brain; and that inflammation gives rise to the softening of 
that organ, which is the favourite opinion of Lallemand, Rostan and 
others ; in that case the brain should be found invariably in a soft- 
ened state, which is not consonant to my observations." But I have 
already shown that modern pathologists do not assert that the effu- 
sion is always caused by inflammation; it is sometimes produced by 
venous congestion, and by any mechanical cause impeding the circu- 
lation. Neither Lallemand nor Rostan attribute the softened state 
of the brain to inflammation of the membranes, which Dr. Monro 
appears to confound with inflammation of the substance of the brain, 
and who has also attributed to Rostan an opinion quite contrary to 
that which Rostan actually maintains. At page 104 of Rostan's 
work already quoted, he explicitly states, that although softening 
is occasionally produced by inflammation of the brain, yet, that it 
sometimes takes place unconnected with inflammation, and is a pecu- 
liar degeneration, which has its own signs and proper characters. 

At page 103, Dr. Monro further urges, that, "If inflammation of 
the brain had given rise to this species of hydrocephalus (acute,) the 
attack of the disease should be sudden and well marked, and its 
course rapid, like to that of phrenitis; whereas the origin of the dis- 
ease is generally not well marked ; indeed, so much so, as often to 
escape the notice of the parent, and even that of the experienced 
physician." And he further states, that " It is admitted, even by 
those who impute hydrocephalus to an inflammation of the brain, 
that the symptoms of phrenitis are well marked, whereas those of 
hydrocephalus are often very obscure." It has already been shown 
how very insidious inflammatory affections of the brain are, even in 
adults; they cannot be more so in young subjects; but the reader 
shall see what Cnllen himself says on phrenitis in his " Outlines," 
at page 103. " Many of the symptoms by which this disease (phre- 
nitis) is most commonly judged to be present, have appeared, when 
from certain considerations it was presumed, and even from dissec- 
tion it appeared, that there had been no internal inflammation; and, 
on the other hand, dissections have shown that the brain had been 
inflamed when few of the peculiar symptoms of frenzy had be- 
fore appeared." And Dr. Monro concludes, that if acute hydroce- 
phalus be owing to an inflammatory state of the brain," there ought 
to be no distinction as to the symptoms, origin, progress and conse- 
quences of phrenitis and hydrocephalus." To make the statement 
still Stronger, he quotes Cnllen's erroneous definition of phrenitis, 
and then states, with great self-complacency, that " The symptoms of 
this species of hydrocephalus do not correspond with the above defi- 
nition." 

'• One of the most striking features of inflammation of the brain, 

(says Dr. Monro, at page I'M.; is tbe slat-' of tin' pulse; but that 

eharactei i^ also wanting in hydrocephalus j for the state of the pulse 
is widely different From that of a person affected by apoplexy or in- 
flammation of the brain. It is not full as in the former, or hard as 

17* 



562 HYDROCEPHALUS. 

in the latter. It is no doubt quick, as in other diseases which are the 
effect of debility. Besides, no author, who has described the symp- 
toms of phrenitis, has stated that the pulse becomes slower some time 
after the commencement of the disorder." — It is almost unnecessary 
to comment upon the erroneous statements made in these passages ; 
but this opportunity may be taken to mention, that Morgagni has 
clearly shown the great varieties of the pulse in acute diseases: and 
there are few practitioners of the present day who are not well ac- 
quainted with the varieties of the pulse in cases of affections of the 
brain. Dr. Abercrombie, in giving a general view of the symptoms 
which indicate inflammatory affections within the head in adults, 
makes the following observation at page 12. " The pulse is about 
the natural standard or below it, frequently about 60." And again : 
" The pulse having continued from 70 to 80 through the whole 
course of the disease." After alluding, at page 14, to the circumstance 
of the pulse becoming slower some time after the commencement of 
the disease, he observes, "As the pulse falls, the patient is disposed 
to sleep; this is, perhaps, considered as favourable; it falls to the 
natural standard; he then sleeps almost constantly; and in another 
day this sleep terminates in coma. The pulse then begins to rise 
again ; it rises to extreme frequency, and, in a few days more, the pa- 
tient dies." 

Is it not a curious circumstance, that Cullen, in the seventy lines 
that he has written on inflammatory affections of the brain, does not 
notice the state of the pulse? Neither does he mention it in his 
definition. 

At page 1 10, Dr. Monro endeavours to establish an invariable con- 
nection between hydrocephalus and dropsy, both depending on 
debility; now, if this were true, children ought to be very liable to 
dropsical affection in other parts of the body, which is decidedly not 
the case ; but, nevertheless, looking pathologically at these affections, 
there is a strong analogy. Dropsy sometimes arises from inflamma- 
tion; so does hydrocephalus. Dropsy sometimes arises from morbid 
alterations in the structure of the heart; so does hydrocephalus. 
Dropsy is sometimes produced by disease of the lungs, and particu- 
larly bronchitis ; so is hydrocephalus. Dropsy in the belly frequently 
depends on diseases of the liver impeding the circulation; so does 
hydrocephalus occasionally depend on obstructions in the venous 
system of the head. Dropsy sometimes depends on diseases of the 
kidneys; so does hydrocephalus. Lastly, dropsy is sometimes cured 
by bleeding ; so is hydrocephalus ! 

Treatment of acute hydrocephalus. — If so much discrimination is 
required in the treatment of inflammation of the brain in adults, still 
more is necessary in treating the disease in young subjects. With 
respect to bleeding, in particular, much depends upon the duration of 
the disease, the age and peculiarities of constitution of the child, and 
whether the disease has taken place subsequent to other disorders, in 
the course of which the child has been much weakened. But if called 
early, no lesion having as yet taken place in the brain, and the child 
being above two years of age, I have no hesitation in opening a vein, if 
one is anywhere to be found. This recommendation is urged after 
considerable experience of its advantages, in controlling diseased 



HYDROCEPHALUS. 5S3 

action in the brain at an early period of the disease, and from which 
I have never seen any bad results. It would appear that the danger 
of bleeding children from a vein is far overrated. In two cases, the 
bleeding produced syncope, and yet no bad consequences followed. 
Capuron says, at page 495,* "It is sufficiently proved, that general 
and local bleeding are the means of fulfilling the first of these two 
indications, above all in the beginning, where every thing announces 
a movement of reaction towards the head ; apply leeches round 
the neck, open the jugular vein or the temporary artery, and be not, 
like Dr. Odier, afraid of breaking down the vital powers; these are 
too energetic, particularly during the first period, when they tend to 
concentrate themselves towards the head, to irritate the brain, to pro- 
duce a turgescence of its vessels, to leave traces of inflammation, and 
to produce effusion." It is impossible to give any particular direc- 
tion as to the quantity of blood which ought to be abstracted. The 
operation is to be performed when there is high excitement only, and 
in the earliest stage of the disease. In other circumstances, leeches 
must be applied to the feet, which may be afterwards placed in warm 
water, to encourage the flow of blood; and when it is wished to pre- 
vent further loss, pressure can be conveniently and effectually used. 
A great error is committed by practitioners allowing the effect of the 
first bleeding to be entirely lost, and not following it up, either by 
taking an additional small quantity after a short interval of two or 
three hours, or applying leeches. Another error is frequently com- 
mitted by allowing leech-bites to drain blood from the system by slow 
degrees, thereby producing great weakness without affecting any 
diminution of the diseased action. Antimony is sometimes of signal 
benefit in these cases. Cold applications to the head, purgatives, 
and all the other remedies mentioned so fully when treating of in- 
flammation of the membranes of the brain, must be employed ac- 
cording to circumstances. The gums should be always carefully ex- 
amined, and lanced if necessary. Mercury has been highly extolled 
in the treatment of this disease; but principally by those who regard 
u as a disease of debility, terminating in dropsy, and not one of in- 
flammation. There are only two classes of cases in which this 
remedy ought to be trusted to; — 1. Those in which we are called 
too late to employ the most powerful antiphlogistic means; and 2. 
Theee in which these means have been employed without decided 
amendment 

In subacute cases, as well as in those of an acute nature, after 
the force- of the disease lias been subdued by the appropriate reme- 
dies, I have seen very beneficial results from the production of a 
pustular eruption on the head, with the tartrate of antimonial oint- 
ment. This is only following the steps of nature, it having been 
often observed that threatening symptoms have subsided upon the 
occurrence of porrigo or some other cutaneous eruption. When the 
diieaei has adVanced to its last stage, it has been proposed to draw 
oil' the grafter by tapping the brain. Hut the water is nut the die- 

ea8fl ; ami, therefore, UnTeei the diseased action were cured, and the 
healthy condition of the brail restored, it is of no use to draw oil' 

♦ Train) dcs Maladio deb Enfans jus.ju'a la l'ubcrlO, 1830. 



564 CHRONIC HYDROCEPHALUS. 

the water; not to speak of the danger and uncertainty of such an 
operation, even when performed by the most skilful hands. What- 
ever good effects are represented to have been produced in chronic 
cases of hydrocephalus, no benefit can be expected from such an 
operation in the acute form of the disease. 



CHRONIC HYDROCEPHALUS. 

Sometimes, in young subjects, acute hydrocephalus runs into the 
chronic form, and constitutes one variety. 

A second variety, the effect of very slight inflammatory action, 
may be very insidious, and slow in its progress. A child so affected 
shows marks of suffering, with loss of flesh ; but there are no de- 
cided symptoms, till perhaps a stranger remarks its head to be much 
larger than it ought to be. The head may go on enlarging slowly 
for a number of years, remarkable instances of which are on record; 
or if the disease attack a very young subject, the bones of the head 
separate to a considerable extent. 

A third variety is sometimes observed, in which the head, perhaps 
very large originally, does not become larger during the course of the 
disease; but the bones are found to be remarkably thin, and some- 
times after they have become so, the sutures are so much weakened 
and their mechanism so much altered, that slight separation of the 
bones is observed. 

Children affected in the manner described in the first variety, sel- 
dom live so long as the others; and in the third variety, shorter than 
those in the second, who may live for twenty or thirty years; and it 
is an interesting pathological fact, that in all the varieties death is 
often occasioned by some other disease, very frequently ulceration of 
the bowels, sometimes phthisis pulmonalis, and occasionally an in- 
flammatory affection of some of the tissues of the lungs. 

The symptoms vary much ; and, in some cases, it is difficult to 
conceive how children, under such extensive disease, preserve their 
intellectual faculties. Occasionally the sense of sight, hearing and 
taste are destroyed permanently, or only for a time ; in some, one 
sense only is affected ; in others, two or more, the rest remaining en- 
tire. Emaciation is a common symptom, as is also some degree of 
giddiness in the erect posture. The bowels are in different conditions; 
but when diarrhoea is intractable, and in some cases even when very 
slight, I have found after death extensive ulceration in the mucous 
membrane of the bowels. Strabismus is frequently, and opacities of 
the cornea are occasionally, seen in this affection. In some instances, 
convulsions are very violent, many of the muscles remaining con- 
stantly rigid; the convulsions may be general, like those of the 
epileptic kind, with foaming at the mouth ; or they may be partial, 
affecting one or more of the extremities, or the muscles connected 
with respiration, or, perhaps, only those of the face. 

Appearances on dissection in chronic hydrocephalus. — The 
membranes of the brain are generally very vascular; the veins some- 
times very large and turgid. In three instances of chronic hydroce- 



CHRONIC HYDROCEPHALUS. 565 

phalus, I found extensive traces of disease in the longitudinal sinus: 
in one, it was almost obliterated by the thickening of its coats ; in two 
others, the area of the vessel was very much diminished, partly by 
thickening of its coats, but principally by deposition of lymph in its 
cavity partially organized, and requiring some degree of force to 
separate it. 

The collection of water in the ventricles sometimes amounts to 
several pounds; and in cases where the effusion is considerable, the 
convolutions of the brain become more and more obliterated, from 
the distension occasioned by the fluid, and in some instances I have 
seen them completely unfolded. The ventricles will be found largely 
developed, the lining membrane occasionally vascular, and frequently 
thickened ; I have seen this membrane as thick as the rind of an 
orange, and easily separated from the surrounding brain, which was 
softened. The brain itself is occasionally of a natural consistence; 
at other times it is softened. In some cases, particularly where the 
convulsions have been violent, considerable effusions, presenting 
more or less of the appearance of lymph, have been found, involving 
the central parts at the base of the brain. 

In some instances, the effusion has been seen external to the brain 
itself, which has been described as a variety, under the term "exter- 
nal hydrocephalus." Not meaning to deny the existence of such a 
case, I feel convinced, from my own examinations of brains, where 
the effusion appeared to be external, that in fact it was owing to the 
fluid having found its way out of the ventricles, and distending to a 
great degree the arachnoid coat alone ; one instance of which occurred 
to me a few years ago, and another lately. 

Treatment of chronic hydrocephalus. — In the treatment of cases 
of this nature, the chief object of the physician is to palliate symp- 
toms as they arise, by the occasional application of leeches, the fre- 
quent use of blisters or issues, and the contra-irritation produced by 
tartar emetic sprinkled upon the surface of a pitch plaster; attention 
to the bowels, regulating the diet, together with the administration 
of an occasional small opiate. Mercury has been much praised in 
this form of the disease; and although 1 have never seen any benefit 
arise from its employment! yet there can be no objections, in any case, 
tu a l ai( trial of its powers. 

When considering the treatment of acute hydrocephalus, I stated 
my disapproval of the irrational practice; of puncturing the brain to 
draw oil' the effused fluid ; hut 1 will not venture to Bpeak so decid- 
edly against the practice in chronic cases. If the operation of tap- 
ping the brain is ever to prove successful in producing a cure, it must 
be in chronic cases, where an inconsiderable quantity of fluid is 
effused, or where there is no considerable organic lesion. Neverlhe- 
sperienced pathologists will, I am persuaded, join me in stating 
that such cases an: exceedingly rare ; so rare as not to be met with 
oftener than once m a thousand instances ! 

n highly extolled : of course it must he employed 
afh-r the operation of lapping. Similar remarks to those already 

made respecting the results to he expected from that operation, are 

applicable to the effect! to he expected from pressure. 



CHAPTER III. 
DISEASES OF THE SPINAL MARROW. 



Inflammation of the Spinal Marrow and its Membranes; and 
under this head I shall at present include Tetanus — Trismus — 
Trismus Nascentium — and Hydrophobia. 



INFLAMMATION OF THE SPINAL MARROW AND ITS MEMBRANES. 

It has been considered expedient to treat of inflammation of these 
tissues together, because it does not appear to be established that in- 
flammation in one texture has such distinctive characters as to enable 
us to distinguish inflammation of the membranes from inflammation 
of the substance of the spinal marrow. We are indebted for many 
important observations on this subject to several French writers and 
Dr. Abercrombie; nevertheless, systematic authors must be slow in 
drawing practical conclusions from them, until they be more nume- 
rous, and more fully elucidated. 

Symptoms of inflammation of the spinal marrow and its 
?nembranes. — The chief symptoms of inflammation of these parts 
are stated to be pain in the back, occasionally shooting upwards and 
downwards, being very severe in one spot, increased by motion, but 
not always by pressure, unless it be connected with caries of the 
bone ; rigors ; some degree of fever; headache; slight incoherency, 
and even coma occur. In some cases dysuria takes place ; in others 
retention of urine ; convulsions sometimes general, at other times 
partial ; rigidity of the muscles of the back and neck. Sometimes 
the body is bent backwards, in a state called opisthotonos; in some 
extremely rare cases, the body is bent forwards, in the state termed 
emprosthotonos. Sometimes there is locked-jaw, and occasionally 
complete tetanus. Sometimes there is great pain or tingling in the 
extremities, particularly in the lower; and occasionally paralysis, not 
only of the lower, but of the upper extremities. When the superior 
extremities are affected with pain, tingling, convulsions or paralysis, 
it is stated that morbid appearances have been found in the cervical 
region. In some instances, the limbs are permanently contracted, 
rigid and painful ; while in other cases they are flaccid and without 
pain. The muscles of deglutition are occasionally affected, sometimes 
so much so that there is a dread of swallowing any fluid, and in this 
way the disease stimulates hydrophobia ; and there is reason to be- 



DISEASES OF THE SPINAL MARROW. 567 

lieve this class of diseases has been often mistaken for the latter. 
The functions of the stomach and bowels are deranged ; at first, the 
bowels are constipated and moved witli difficulty, but towards the 
last, stools are passed involuntarily, as in the urine. The tongue 
presents different appearances; from being loaded and moist, it be- 
comes dry and hard. The pulse is various, and has no particular 
character. The faculties of the mind, generally speaking, are not 
much impaired, although there is occasional incoherency. Some 
allege that it is only when the disease is situated high in the cervical 
region that the functions of the brain are impaired. When they are 
permanently, disordered and particularly, if blindness and deafness 
take place, it may be concluded that the brain is also affected. The 
respiration, in many cases, becomes slow as the disease advances, so 
much so, that there may be so few as ten, seven, five or even three 
inspirations in a minute; occasionally death is suddenly produced by 
asphyxia. 

Sometimes the disease terminates fatally in a few days, but the 
general course of its acute form is from ten to fifteen ; it would ap- 
pear, however, that it may exist in a chronic state for an almost inde- 
finite period. In the practice of French physicians, we are told this 
disease has been very generally fatal; but 1 have seen a number of 
severe cases treated successfully, which, there was every reason to be- 
lieve, were inflammation of the spinal cord and its membranes, but 
by means very much bolder than those which are generally pursued 
on the opposite side of the Channel. If the disease be produced by 
caries of the vertebrae, or by blows causing considerable injury to the 
bones, it will generally prove fatal, at least much more frequently so 
than when it occurs spontaneously. Probably many affections which 
now go by the vogue name of nervous, and many of the painful 
sensations in the chest and abdomen, experienced particularly by 
females, will hereafter be found to depend upon some functional 
derangement, or slight disorganization of the spinal marrow and its 
membranes. 

Causes of inflammation of t/tr spinal marrow and its mem* 

oranes. -This disease may be produced by the application of cold, 

licularly ill damp situations; fatigue, and every other circum- 

• winch may upset the balance of the circulation, and produce 

ma engorgement in different organs; as also by blows, caries of 

the vertebrae, and tumours growing from different parts within the 

vertebral canal. 

Appearances on dissection in inflammation of the spinal-mar* 
row ditii its membranes. — It may i": remarked, that the description 
given of the morbid appearances of the brain and its membranee, 
will equally apply to the spinal marrow and its membranes. The 
effusion will be found beneath the arachnoid. ' The reader must keep 
m mind, that there is always a considerable quantity of serous tluid 
m the spinal canal, winch has a ine communication with the ven- 
tricles i.t" the brain j and that tin- spinal marrow is rather harder than 
th'- snl.-' ince "I the brain. 

Treatment of inflammation of the spinal marrow and its mrm- 
branes. — This consists in bleeding, generally and locally; the frequent 



568 [SPINAL IRRITATION.] 

administration of purgatives ; the application of contra-irritation, and 
attention to the bladder, to prevent over-distension. In this, as in 
all diseases affecting vital organs, the life of the patient depends upon 
the timely application of the proper remedies, which must be made 
assiduously. Some cases, thought to be of the nature of those now 
under description, have been successfully treated, by applying twenty 
or thirty leeches, after copious general bleeding, and by reapplying 
them, (even in increased number,) to the part chiefly affected, till 
the disease was subdued ; and by the exhibition of repeated doses of 
calomel and opium.* 



[spinal irritation.] 

[In addition to the preceding account of the diseases of the spinal 
marrow, I shall now offer a few remarks on those modifications of 
disease which have of late been referred to irritation of the spinal 
marrow and nervous ganglia. 

It must be confessed that some of the advocates of these views 
have given them a much too general application; yet it cannot be 
denied that they are of great practical value, and should be familiar 
to every physician. 

As the basis of the doctrine of spinal irritation, it is assumed that 
"disease of the larger nervous masses, as the brain and spinal mar- 
row, is not so much evinced by phenomena in the immediate seat 
of disease, as in those more remote parts to which the nerves arising 
from the diseased portion are distributed."* Hence it is, that se- 
vere neuralgia of the limbs may be attended by comparatively trivial 
uneasiness in the spinal cord, while the latter is the real source of 
the irritation, and the part to which the curative means should, be 
directed. It often happens that the patient is wholly unconscious of 
pain or sensitiveness of the spine, until the latter has been subjected 
to some degree of pressure, when the connection becomes manifest 
by the occurrence of a neuralgic paroxysm. In other instances the 
secondary effect consists in numbness, or in a sensation like fatigue; 
and again, in very many cases, the spine itself may be very sore to 
the touch, and yet pressure there has no obvious effect on the remoter 
symptoms ; so that the connection between them is rather to be in- 
ferred from other circumstances. 

Let us now briefly inquire into the symptoms of spinal irritation 
in connection with the distribution of the nerves. 

1. Irritation of the medulla oblongata, and the nerves arising 
from it, (especially the 5th pair,) gives rise to those painful affections 
of the face called tic-doloureux. 

2. Irritation of the upper cervical cord gives rise to neuralgic 
pains of the scalp, and a stiffness and sense of fatigue in the muscles 
of the neck. 

* The last work written exclusively upon this subject, is that of M. Oliver, of 
Angers, entitled " De la Moelle epiniere et de ses Maladies." 

[t Teale on Neuralgia, p. 3.— I have freely availed myself of this valuable work 
on the present occasion.] 



[SPINAL IRRITATION.] 569 

3. Irritation of the lower cervical cord produces its effects on the 
shoulders and upper extremities. 

4. Irritation of the upper dorsal cord causes uneasiness in the 
chest, and is supposed to give rise to that affection of the intercostal 
muscles called pleurodynia. 

5. Irritation of the lower dorsal cord induces soreness and pain 
in the inferior part of the chest, and especially a sense of constriction 
of the epigastrium, and pains of the abdominal muscles. 

6. Irritation of the lumbar and sacral cord gives rise to pain, 
spasm and other uneasiness in the lower extremities, and especially 
a feeling of instability in walking. 

These sensations are sometimes intermittent, sometimes constant; 
atid they present a diversity of character which it would be both 
difficult and tedious to describe. Pain of every grade; spasm, tre- 
mors, debility, weariness, coldness, numbness and loss of feeling, are 
among the more common symptoms — symptoms which are not un- 
frequently attended by great physical suffering, and which, for 
want of our ability to explain them, have been too often considered 
imaginative, and therefore unworthy of attention. 

Mr. Teale has also drawn the attention of the profession to an 
analogous irritation of the ganglia of the sympathetic nerve. He 
observes, that this disease of the ganglia is seldom found except in 
conjunction with that of the corresponding portion of the spinal cord, 
whereas the latter is often affected without implication of the former. 

This irritation may occur in any of the sympathetic ganglia, but 
those most frequently affected are the middle and lower thoracic, 
and the cervical ganglia. The organs which derive their nerves 
from these sources, are the seat of a series of symptoms of which the 
following are the most common : palpitation of the heart, asthmatic 
breathing, gastric disease of various grades, as spasm, gastrodynia, 
flatulence, pyrosis, pulsation in the epigastrium, and, in fine, all the 
indications usually called dyspeptic. Leucorrhcea and irregularities 
of tin: catamenia also take place from this cause, together with various 
perversions of the other secretions. 

.Mr. Tate, an English surgeon, has, within a few years, called the 
attention of the profession to the manifest connection between hys- 
teria and spinal irritation; which views, however, will be brielly 
noticed in the chapter on hysteria. 

As yet we know very little of the absolute pathological condition 
of the spinal marrow and nervous ganglia, under the circumstances 
BD0V6 described: they appear, however, to be in a "subacute in- 
flammatory state," which is extended to their envelopes, and, by 
continuance, to the adjacent integuments: for on no other principle 
can we account for the extreme sensitiveness which sometimes exists 
in the course of ihe spine, and which is aggravated by very Blight 
pressure. Some physicians seem unwilling (o acknowledge thai this 
tenderness of the Integuments of the spm'- can arise from irritation 
of the nervous masses which are deeply shut up in ih<' bones of the 
vertebral colomn. Some have even considered tins objection as an 
insuperable difficulty in the riew before us: but oh this point we 
may draw a familiar illustration from an inflamed tooth, which, if 
•18 



570 [SPINAL IRRITATION.] 

not soon relieved, renders the adjacent integuments acutely sensible 
to the slightest violence, and will even cause extreme neuralgia of 
the whole corresponding side of the face. Now, in this instance, the 
nerve which supplies the tooth, and which is the primary seat of the 
irritation, is as completely enveloped by the maxillary bone as the 
spinal ganglia are by the vertebrae. However isolated either may 
appear at first thought, it will be found that there are connections 
between them and the surrounding parts, which fully account for 
the propagation of disease from one to the other; and that this dis- 
ease will consecutively affect the nervous mass, its bony envelope, 
the periosteum and the integuments, until the skin itself becomes 
acutely sensible. Of the latter fact a singular example is given in a 
late quarterly journal (British and For. Med. Rev.,) in which the 
act of passing the finger lightly over the fine hairs covering the nape 
of the neck, threw the patient into an agony. 

Spinal irritation is not necessarily connected with disease of the 
vertebrae, although the two may coexist. I have lately met with a 
remarkable case of spinal irritation in which the vertebrae do not 
appear to be involved ; and yet on each side of the upper portion Of 
the sacrum a distinct tumefaction can be felt, upwards of an inch in 
diameter, very sore to the touch, and accompanied by neuralgic 
pains of the lower extremities, great weariness in walking, and 
various dyspeptic symptoms. This disease had continued upwards 
of six years before I saw it: it is irregularly paroxysmal, and has 
tended much to enfeeble a previously delicate constitution. 

Treatment.— \i may be briefly mentioned, that almost all the 
ordinary counter-irritants have been resorted to in these derange- 
ments, together with local depletion in the course of the spine. Cups 
or leeches, followed by blisters, constitute our principal resources; 
but after the acute symptoms have been relieved by these or analo- 
gous measures, irritation of a more permanent kind should be insti- 
tuted without delay. For this purpose the tartar-emetic ointment 
answers best. Many cases yield to the first application of these 
remedies; but others require a much more prolonged treatment. 

The usual mode of applying tartar-emetic to the spine is by means 
of the tartar-emetic ointment, formed by mixing one drachm of the 
mineral salt with an ounce of simple cerate. Much time, however, 
is often lost in waiting for the effect of this uncertain preparation. A 
much more active formula is that recommended by Dr. Hannay, of 
Glasgow, viz.: 

R. — Tartrat. Antimonii, 3'- 

Muriat. Hydrargyri, gr. v. 

Aquae distillatae, t ^i. 

Spiritus Lavend. Compos., gi. Dissolve the salts in water, and then add the 
spirit. 

This solution is applied by wetting the fingers with it, and then 
rubbing them on the skin. To be still more effectual, portions of the 
antimony itself (much of which remains undissolved,) may be rubbed 
on : by these means, persisted in for 10 or 15 minutes, an eruption 
will invariably follow in a few hours. 

When tartarized antimony is applied, or a Burgundy pitch plaster, 



TETANUS. 571 

as is sometimes done, it may be very difficult to remove it when the 
irritation comes on, and the patient may hence suffer much unneces- 
sary distress. 

It is important to know that during the operation of tartarized 
antimony, the nervous symptoms are often greatly aggravated, and 
the relief is not to be expected until the eruption begins to decline. 
Care should be taken not to allow the irritation to exceed a reason- 
able limit, for which purpose its progress must be watched from day 
to day; and if by any chance it becomes too severe, a starch or bread 
and milk poultice is well calculated to mitigate the pain. 

Galvanism, as directed in the chapter on epilepsy, and moxa have 
occasionally produced remarkably good effects. 

"Where the case is not sufficiently severe to justify the employ- 
ment of either of the preceding applications," observes Dr. I. Parrish, 
" or where, from the suddenness of the attack, it is desirable to pro- 
duce a speedy impression in the vicinity of the spinal marrow, fric- 
tions down the spine, with spt. terebinth, either alone or diluted with 
some unctuous matter, or a decoction of capsicum in brandy, with 
other similar articles, will be found highly beneficial."* 

But while our attention is thus directed to the spinal track as one 
of the points of diseased action, we are by no means to neglect the 
various coexisting functional derangements. These require to be 
treated on general principles, by the judicious interposition of ape- 
rient and tonic medicines, with a suitable diet, exercise, and, in some 
instances, change of air. 

In concluding these brief observations, it may be remarked, that 
spinal irritation is not to be viewed as a simple or isolated affection, 
but rather as a complication involving various dissimilar organs, and 
having for its basis a true neuralgic condition. It is a condition from 
which many different diseases are produced, and these, by long con- 
tinuance, tend to impair and disorganize the structures in which 
they are located, however remote from the spine itself; so that the 
BCUtive disease may become infinitely worse than the primary 
irritation : whence it happens that by removing the latter we cannot 
always guarantee the cure of the former; or, in a familiar phrase, a 
chain of morbid actions is established, in which the spinal affection 
becomes a link of bill secondary importance : nor have I a doubt that 
it is itself sometimes a strictly consecutive affection. 

The subject, ill truth, is comparatively new, ami requires abundant 
additional observation and rctlection, before its real merits can be 
ascertained, t] 



'I'm- is a disease characterized by tonic convulsions, and. for the 
!i, by rigidity of the affected muscles. Sometimes the mus- 

[* \" 1 ■ t • ■ I! -..:'. Il I lL, &VC, AllH'i. Jt.lir. \Ii'i|. Sri., AlILT- 1839 i 

afonnaiion on this subject will be obtained from ibe work ol Mi 
i '■' i and from the ingenious add truly practical 

Dr. 1 i ■•v>\.] 



572 DISEASES OF THE SPINAL MARROW. 

cles which close the jaws are solely affected, with perhaps those of 
the neck, when the disease is usually termed locked-jaiv or trismus. 
When the muscles of the back are convulsed and contracted in such 
a manner as to make the body be supported by the head and the 
heels, the trunk being arched, the term opisthotonos has been ap- 
plied. When the body is bent in the opposite direction, the term 
emprostholonos has been used. In a practical point of view, these 
varieties may be considered under the general term tetanus. 

An important distinction, however, must be made between the 
symptomatic tetanus, which is so frequently the result of wounds, 
and that which comes on without any assignable cause, and which 
has been denominated, in contradistinction to the other, idiopathic. 
It affords me much pleasure to hand to the surgeon who boasts of 
the superior success of his art over that of physic, the traumatic 
tetanus in the hope that he may be more successful in discovering 
its true pathology and treatment than his wise ancestors; and I shall 
now proceed to consider that form of the disease which has been 
called idiopathic, and afterwards make a few observations on tris- 
mus 7iascentium. 

Symptoms of tetanus. — Tetanus has no precursory symptoms 
which can be depended upon ; sometimes patients complain of rigors, 
or merely chilliness, with pain and stiffness of the muscles of the 
neck and shoulders, which extend, by degrees, to those of the jaw. 
By and by rigidity of the muscles takes place, accompanied by pain- 
ful spasms; the jaws are immovable, and if not yet completely 
shut, soon become so tightly clenched that it is impossible to separate 
them; deglutition is difficult, at length impracticable; the faculty of 
the speech is impaired, and at last the power is altogether destroyed, 
although intelligence may remain ; the countenance is exceedingly 
anxious; the oppression at the prsecordia is great, together with a 
sense of tightness and suffocation. 

The spasms sometimes extend from the face and neck to the back, 
from whence they spread to the rest of the muscles of the trunk, ab- 
domen and extremities, the muscles always remaining rigid; but 
their convulsive action comes on at regular intervals. In the most 
severe cases, the paroxysms are violent, and the spasms succeed 
each other very rapidly. The oppression at the prascordia increases 
as the spasms extend from the muscles of the jaw and neck to those 
of the trunk, when there come on a severe sense of constriction in 
the chest and a violent darting pain extending from the lower part 
of the sternum to the spine, the return of which the patient constantly 
dreads. The mental faculties, for the most part, remain sound till 
near the approach of death ; which circumstance gives the disease 
a. distinguishing character from epilepsy. The pulse is generally 
little affected in tetanus, even in the traumatic form of the disease; 
occasionally, however, it is quick, particularly towards the fatal 
termination. The functions of the lungs seem to be seriously im- 
peded, respiration being very rapid, or slow, not exceeding three, 
five, seven or nine inspirations during a minute. The skin is seldom 
hotter than natural, that is to say, there is no feverish heat ; the body 
is frequently bathed in perspiration, which, as the disease advances, 



TETANUS. 573 

is converted into a cold, clammy sweat. The functions of the 
stomach and bowels are sometimes unaffected. Deglutition is, in 
many cases, very difficult, which may be partly owing to the tough 
phlegm lodged about the fauces in considerable quantity, and partly, 
also, to the spasmodic action of the muscles. Greater difficulty is 
experienced in swallowing fluids than solids, which the patient is 
apprehensive will produce complete suffocation ; and, if he is a per- 
son of irritable temper, he may, perhaps, show a marked dislike to 
fluids when presented to him, which will give an appearance of 
water-dread. Should such an individual have received a bite from 
a dog, even twenty years before, he will be said to be affected with 
hydrophobia; and I am convinced, after much patient investigation, 
that many of the cases recorded as pure hydrophobia, were nothing 
more than trismus, conjoined with difficulty in swallowing fluids. 
Tetanus is a disease which is very rapid and fatal in warm climates, 
terminating as early as the third day; in this country, it is seldom 
fatal till between the fifth and tenth. The danger of the disease is 
to be calculated by the frequency, violence and duration of the con- 
vulsions. 

Causes of tetanus. — In warm countries, it is believed that the 
black population is more liable to tetanus than the white. Individu- 
als possessing what is termed a nervous temperament, are, perhaps, 
more subject than others. Long-continued fatigue, together with 
exposure to cold damp air, conjoined with the excessive use of ar- 
dent spirits, are the causes usually, and, perhaps, truly assigned. 

Appearances on dissection in tetanus. — Many distinguished pa- 
thologists believe that tetanus has its seat in the spinal marrow, and 
that its nature is inflammatory. There can be no doubt that there 
is a striking resemblance between the symptoms of tetanus, and 
those produced by inflammation of the membranes of the spinal 
marrow. Tetanus, well marked in its symptoms, however, has 
proceeded to a fatal termination, and, upon the most minute exami- 
nation, no morbid appearance could be discovered either in the 
memhraoee or in the spinal cord itself And, on the other hand, in- 
flammation and other organic lesions of this part have been found, 
upon dissection, in cases where uo symptoms of tetanus had mani- 
fested themselves. Others allege that the ossific scales, found on the 
surface of the arachnoid membrane of the spinal marrow, are the 
cause of tetanic convulsions ; but I have frequently seen these ossi- 
fications where symptoms of tetanus never appeared. — The lungs 
have been often found loaded with blood; but this can scarcely 
have any connection with the causes of the disease; it is, perhaps, 
only an effect of the impeded respiration. It is snu\ that the cardiac 

portion of the stomach and the lower end of the OBSOphagUS have 

always been found inflamed) and attempts have been made to con- 
nect the occurrence of the disease with tins appearance; but were 
this .l cause of tetanus, it would he a disease of very frequent oc- 
currence in these latitudes. A similar remark applies equally to 
worms having been occasionally found m tin; alimentary canal, hot 
they may possibly give rise, m some Constitutions, to symptomatic 

tetanus, 

48' 



574 DISEASES OF THE SPINAL MARROW. 

Treatment of tetanus. — After a careful review of the cases 
recorded in the annals of physic, no plan of treatment, hitherto em- 
ployed, seems to have been attended with much benefit. Bleeding, 
purging, cold and warm bathing, all the most powerful narcotics, 
and mercury, have each had its warm supporters, but with little suc- 
cess. The following is the plan which I would adopt in cases of 
tetanus, including those of locked-jaw, in previously healthy sub- 
jects. If called early, the strength being good and the pulse not 
very rapid, I would bleed from the arm till the near approach of 
syncope; by this means, plethora will be reduced— any determina- 
tion of blood will be altered — and any tendency to inflammation, if 
such exist, so far at least subdued. But venesection ought not to be 
employed if the disease had made much progress, or if the pulse 
were very rapid, the tongue dry, and the strength reduced by the 
diseased action. In an hour or two after the general bleeding, blood 
should be abstracted locally in the course of the spine, either by 
applying a considerable number of leeches, or by means of cupping- 
glasses, which ought to be repeated from time to time, according to 
circumstances. The bowels must be kept freely open ; but much 
mischief has been done, and the spasms rendered more violent, by 
the constant exhibition of drastic purgatives. Tobacco enemata 
have long been used,* and have of late years been again strongly 
recommended in this disease by Dr. O'Beirne of Dublin. Opium, in 
5 grain doses, ought to be exhibited every 2d, 3d or 4th hour, ac- 
cording to circumstances; or what is better still, a hundred drops of 
laudanum, sixty or seventy of Battley's sedative solution, or half- 
grain doses of acetate of morphia. From the beneficial effects pro- 
duced by colchicum in gout and rheumatism, in both of which the 
nervous system is very much implicated, large doses of that medi- 
cine might be conjoined with the opium. Patients labouring under 
tetanus appear to bear immense doses of opium: many cases are re- 
corded, in which twenty and thirty grains have been exhibited daily, 
and persevered in for two or three weeks without causing any appa- 
rent bad consequences. Mercury has been much in favour among 
medical men in the treatment of this disease, and it has been asserted 
that those patients have recovered in whom salivation had been ex- 
cited ; but there is a great deception likely to arise from this state- 
ment. It is difficult to excite this action in violent diseases, which 
run on rapidly to the destruction of life: the very severe cases run 
through their course in too short a period of time to allow the mer- 
cury to act; therefore it can only be in the slighter varieties of the 
disease in which the action of the remedy can take place, and which 
might be cured by other means. The remedy, however, has been 
too strongly recommended to be passed over. A large blister should 
be applied to the spine. As to cold and warm bathing, it may be 
shortly stated, that I have no faith in either, as the least motion will 
very generally produce a paroxysm. The strength must be carefully 
watched, and nourishment, with or without a little wine, should be 
given at short intervals, long before there is any decided appearance 

* Vide Observations by Mr. Duncan, 11th vol. Ed. Med. and Surg. Journ., p. 198. 



TRISMUS NA8CENTTUM— HYDROPHOBIA. 575 

of sinking. When the stage of collapse approaches, stimulants must 
be had recourse to, and there can be no doubt that their judicious 
exhibition has occasionally saved lives. Among other remedies, 
which have been recommended, I may mention assafoetida, musk, 
camphor, valerian, bark, sudorifics, ammonia, carbonate of soda, &c. 



TRISMUS NASCENTIUM. 

I have now to say a few words respecting the locked-jaw of in- 
fants. It is a disease seldom seen in this country, and is more pecu- 
liarly an affection of negro children in warm climates; attacking 
them between the 7th and loth day after birth, seldom later than the 
17th, and, in general, neither preceded nor accompanied by any 
febrile movement. The disease steals on in the following manner. 
Children lose flesh and strength, and are affected with drowsiness 
and frequent yawning ; they suck with increasing difficulty, and at 
last are unable either to snck the breast or to swallow; the skin gra- 
dually puts on a yellow appearance; by and by the jaw is observed 
to become stiff, its muscles rigid ; general convulsions sometimes pre- 
cede death, which often happens in two or three days from the first 
attack. 

The true pathology of this affection has evaded the efforts of all 
inquirers. It has been attributed to irritation produced by tying the 
navel-cord; to the irritable state of the umbilicus upon the separa- 
tion of the cord at the natural period ; while others maintain that it 
is owing to some diseased state, or retention of the meconium. 

No treatment hitherto tried appears to have had much effect in 
controlling the disease after it is fairly established; but that which has 
been found most beneficial, is the application of turpentine to the 
navel. 

II the child survive the ninth day without the occurrence of any 
symptoms of the disease, it is considered safe. At one time, in some 
of the West Indian Islands, this disease was so common and so fatal, 
thai, on an average, two out of three infants perished. 



HVHROPHOBIA. 

This is a disease happily of rare occurrence, particularly in this 
country; and, as already mentioned, it is probably of Still rarer oc- 
CtUTence than is generally imagined, being frequently confounded 
with tetanUSj When, aloilg with that disease, there is a dread of liquids; 
but there can he no doubt that such an affection does exist. I once 
saw a patient many years ago, but before I was able to judge of 
BUCtl matters fb( myself, who was said to be affected with hydropho- 
bia: 1! terminated fatally; hut I have never met with a medical man 
who could say he had seen even one case in this country. Hydro- 
phobia i^ produced by a morbid poison generated in the dog, wolf, 
f0Z, and Occasionally, although rarely, in the cat. The poison ap- 
pears to be mixed with the saliva ; and the characteristic of the dis- 
ease produced is a dread of liquids. That such a disease does exist 



576 - DISEASES OF THE SPINAL MARROW. 

and that it is capable of being communicated from one animal to 
another, has been satisfactorily proved by experiments performed in 
the year 1813, by Magendie and Breschet. The saliva of a man 
affected with hydrophobia, was collected and inserted beneath the 
skin of two dogs, which were at the time in excellent health, and in 
thirty-eight days one of the two dogs became rabid, and bit two 
others, one of which died in a month after the same disease. Expe- 
rience has proved, that all the animals bitten are not necessarily affect- 
ed with hydrophobia. Of this fact, Mr. Hnnter gives a striking ex- 
ample. Twenty persons were bitten by one rabid animal, of whom 
only one suffered. It is generally admitted, that the state of the 
mind has a powerful influence in the production of disease ; and it is 
probable that hydrophobia may be sometimes produced by the con- 
stant agitation into which timid, nervous persons are thrown after 
having been bit. Some allege that the virus may remain dormant 
in the system for years before the disease appears; but the general 
opinion is, that it shows itself in between twenty and sixty days 
from the occurrence of the accident. During this period, there is no 
constitutional derangement, unless the individual is depressed by 
fear. 

Symptoms of hydrophobia. — The disease is ushered in by rigors, 
languor, lassitude, severe mental depression, irritability, anxiety, 
restlessness and watchfulness. Occasionally a shooting pain is felt 
in the neighbourhood of the injured part. As the disease advances, 
the anxiety of the countenance, the irritability and watchfulness, the 
oppression at the prascordia and sense of contraction of the chest, 
increase ; slight tumours, affecting every part of the body, appear, and 
difficult deglutition ; a considerable quantity of viscid phlegm is ob- 
served In the mouth and fauces ; stiffness of the jaws now and then 
takes place; as also general spasmodic paroxysms, resembling those 
in tetanus; but it is asserted that, on careful examination, the convul- 
sions will be found to be of the clonic kind. In pure hydrophobia, 
the body is said to be affected more with tremors than convulsions. 
At length the water-dread increases so much, that the sight of any 
thing liquid, or merely an allusion to it, produces a paroxysm of tre- 
mors, at a time too when the thirst is very urgent. On some occa- 
sions, the dread only takes place when the patient attempts to drink. 
As the disease goes on advancing, the least noise or motion made by 
any of the attendants produces a paroxysm, as well as every effort 
on the part of the patient either to move or speak. He manifests 
increasing terror and watchfulness. As in tetanus, the mind gene- 
rally remains entire till towards the termination of the disease. 
The thirst and sense of constriction increase in urgency; respiration 
becomes painfully hurried and short; the pulse and heat of skin are 
generally about the natural standard; but the former increases in 
frequency while the latter sinks towards the fatal termination, and 
the surface is covered with a clammy sweat. Debility, in the pro- 
per sense of the term, is scarcely ever present till towards the last 
stage, when the eye becomes hollow, and the countenance pale and 
haggard. 

The duration of the disease in slight cases is about a week, but in 
those of a more violent nature, two or three days. Mr. Marshall 



HYDROPHOBIA. 577 

informs me, that the last case of this disease which came under his 
notice, died in twenty-two hours from the occurrence of the first sus- 
pected symptom. Two hours before death, his patient ate bread 
and jelly with an appetite. Another case, which Mr. Marshall at- 
tended, terminated fatally in a shorter period. 

Appearances 011 dissection in hydrophobia. — A great many dis- 
cordant statements will be found, in different works, respecting the 
seat of the disease. Some pathologists, after the most careful exami- 
nation, have not been able to discover any morbid appearance what- 
ever in any part of the body; while others have seen vascularity in 
the pharynx, oesophagus, the cardiac extremity of the stomach, and 
even in portions of the intestinal tube, particularly the ileum; and 
these parts have been represented to have been even in a gangrenous 
condition. Magendie found no diseased appearances in the brain. 
Professor Trolliet, of Lyons, published a work on this subject in the 
year 1820.' He seems to have had ample experience in the treat- 
ment of this dreadful malady ; and the following are the diseased 
appearances which he discovered on dissection in different cases, 
ularity and inflammation of the mucous membrane of the air- 
passages, which was coated over with a frothy matter, (according to 
his view,) of a peculiar kind, and which he supposes to contain the 
specific virus ; the lungs were gorged, and apparently emphysema- 
tous ; in some instances air was discovered in the heart and large 
blood-vessels; the blood was black, uncoagulated, and had an oily 
appearance. This gentleman found the membranes of the brain, 
and more especially the pia mater, very vascular. 

One fact has been established by all the individuals who have in- 
vestigated this disease— that the salivary glands, and the surround- 
ing cellular substance, have always been found healthy. 

Treatment of hydrophobia. — Bleeding even to syncope, and large 
doses of opium, have been employed, together with camphor, musk, 
mercury, and almost every other potent remedy in the materia medi- 
ca, without success. To show the extent to which bleeding has been 
carried, I may mention a case treated by Professor Trolliet. The 
nt was hied to the extent of live pounds, when (lie water-dread 
firsl appeared. In a few hours afterwards, the operation was re- 
peated t<> the extent of eighteen ounces, when syncope again took 
In four hours subsequently to the last bleeding, fourteen 
Otincee were abstracted ; and 111 lour hours after that, the patient 
died, being twelve hours from the commencement of the hydropho- 
bia. It was remarked, that the symptoms became more aggravated 
after each bleeding. Notwithstanding the result of this and other 
. I would still he disposed to recommend a similar plan of treat- 
ment tn that I have proposed in tetanus at page 574. 

The injection <>( tepid water into the veins has been practised 
without success. But from the experience we have had of the safety 
of throwing even ten pounds of saline fluid at a time into the vascu- 
n in cases of epidemic cholera, there is little doubt that the 
practice in hydrophobia will be conducted with greater boldness, 
and pro!, ibly attended with better effects. 

Traltf de in r 



CHAPTER IV. 
EPILEPSY— HYSTERIA— CHOREA— NEURALGIC PAINS. 



This is a convulsive disease which affects the voluntary muscles, 
and is characterized by the suddenness of the attack, loss of sense 
and voluntary motion. 

Symptoms of epilepsy. — The fit generally comes on suddenly, 
sometimes with a frightful shriek, and the patient falls down, and 
immediately loses sense and voluntary motion ; convulsions follow 
on the instant ; the muscles on one side of the body are generally 
more violently affected than those on the other; all the muscles con- 
nected with respiration, and those of the face, are always involved. 
The pupils are sometimes dilated : the eyes roll about in a most 
frightful manner, and at last become fixed. The face is frequently 
of a dark purple colour, but occasionally it is pale and haggard. 
The tongue is sometimes thrust with violence out of the mouth; it is 
occasionally caught between the teeth, and severely bitten; a con- 
siderable quantity of phlegm is collected in the mouth, and expelled 
with violence in a frothy state, with considerable noise. The respi- 
ration is always hurried and laborious, which is often produced or 
increased by patients breathing through the clenched teeth, and the 
frothy saliva. The pulse varies much ; in some cases it is very ra- 
pid, in others, preternaturally slow. The affected muscles are not 
constantly rigid, but occasionally become relaxed, and then rigid 
again ; this is the state termed by nosologists, " clonic spasms." The 
duration of the attack varies from a few minutes to half an hour; the 
convulsions cease; the face becomes pale; and the patient may reco- 
ver his senses and power of voluntary motion, either immediately 
or very slowly ; his judgment is, in general, for a time impaired, and 
he is left debilitated, with the feeling of weight in the head, or actual 
headache. The paroxysm sometimes terminates by violent vomit- 
ing. Occasionally it. happens that one fit succeeds another till the 
patient becomes comatose, and dies; but comparatively few die dur- 
ing a fit, unless the disease has existed for a considerable period of 
time. 

An epileptic paroxysm is occasionally preceded by a peculiar and 
painful sensation in a distant part of the body, as in the fingers, toes, 
or some part of the abdomen, and is described as proceeding in a 
gradual manner, like something creeping towards the heart, in other 



EPILEPSY. 5-9 

cases towards the head, when the convulsions commence. Tin's is 
called the aura epileptica. The attack is also occasionally preceded 
by certain symptoms which announce its approach to the patient, 
but which he has usually no time to communicate ; these are, head- 
ache, imperfect or erroneous vision, sparks of fire before the eyes, 
and tinnitus aurium. 

Females appear to me to be more liable to this disease than males. 
It is not entirely confined to man, as I have seen.it in horses — 
in dogs, particularly of the Newfoundland breed — in poultry and 
pigeons. 

Causes of epilepsy. — Epilepsy appears to be occasionally here- 
ditary. I have known it to be the cause of death in both father and 
son ; but it is more frequently an acquired disease. Idiots are often 
also epileptics; and insanity frequently terminates in epilepsy. Fright 
is said to be a cause: and every kind of mental agitation. Thus, it 
was formerly called the electioneering disease in England, because 
it so often occurred at such periods from violent mental excitement, 
aided, however, by another cause, the abuse of intoxicating liquors. 
Indigestible articles of food, and constipation, by occasioning irrita- 
tion in the stomach and bowels; the irritation produced by worms 
in the intestinal tube, are also very frequent causes; as is likewise 
excessive venereal indulgence. This complaint has been attributed 
to tumours in the brain, and projections of bone arising from the in- 
ner table of the skull. 

Appearances on c/issectioji in epilepsy. — A great variety of or- 
ganic lesions has been discovered in the brain and spinal marrow of 
epileptics. Congestion of the vessels of the brain; thickenings and 
indurations of the membranes ; inflammations; exostoses; tubercles 
and tumours of different kinds, and in different parts of the brain — 
sometimes situated externally to the membranes; at others occupy- 
ing the very centre of the cerebral mass. Some assert that these 
disorganizations are exclusively confined to the cerebellum; others 
to the spinal marrow; but these are to be regarded only as assertions 
niadi: by individual:-;, whose observations have been made upon a 
limited scale. It must be observed, thai any one of these morbid 
appearance! may exist, and even several of them combined, without 
producing that combination of symptoms which constitutes the dis- 
ease tinder Consideration'; and further, that in some instances, upon 
the most careful examination, no morbid appearance whatever has 
been discovered, either in the brain or spinal marrow. Worms have 
frequently been found in the intestines; and this has led several 
pathologists I" assert, that their presence is the sole cause of epilepsy ; 
but ill a great number of instances, not a vestige Of these animals 

could l>e discovered, or any lesion in any pari of the body. So that, 
notwithstanding all the attention winch has been pud to the. investi- 
gation Of the nature and seat of this disease, we are left Very BlUCh 
in the dark'. 

E£pilepsy appears t<> !"• a functional disease of the brain and ner- 
vous system, produced by a variety of causes, sometimes by mental 
emotions, at others, by various irritations affecting the digestive 



580 EPILEPSY. 

organs ; and very frequently by some of the above-mentioned organic 
lesions of the brain and spinal marrow. 

Treatment of epilepsy. — Experience has convinced me, that much 
can be done for epileptics in preventing attacks; but almost every 
thing must be done by the patient himself in the intervals. I have 
seen little benefit from any mode of treatment during the paroxysm, 
except by placing the sufferer in the horizontal posture, and taking 
such precautions as will prevent him from being injured by the 
violence of the muscular commotion into which the body is thrown. 
One of the first circumstances to be attended to is to put something 
between the teeth to prevent injury to the tongue, and the garments 
must be loosened, particularly stays and neckcloths ; and it is often 
very serviceable to sprinkle the face with cold water, particularly 
when the convulsions are confined to the muscles connected with 
respiration. 

After the paroxysm is over, the patient should be kept quiet, the 
heat of the body supported, the bowels opened as speedily as pos- 
sible, and light nourishing food in moderate quantity allowed. At 
no time should a patient load the stomach. The abuse of stimulants 
is to be abstained from, and every cause, corporeal as well as men- 
tal, which can possibly have the effect of disturbing the balance of 
the circulation, or exciting the nervous system. If there be marks of 
diseased action in the brain, the treatment must be more rigid; occa- 
sional cupping may be had recourse to, and if there be considerable 
plethora, a bleeding from the arm may be serviceable, together with 
keeping the head shaved, and the introduction of a seton in the neck; 
or a drain is to be made by means of an issue applied to any other 
part of the body. If worms be suspected, turpentine and other an- 
thelmintics should be exhibited. 

With respect to blood-letting, I have often seen it had recourse to, 
both during the paroxysm and in the intervals. It certainly has 
been sometimes serviceable in plethoric subjects; but in general, it 
does not appear to have any beneficial effect, and occasionally has 
been injurious ; therefore it is a remedy which ought to be used with 
great discretion. 

It has been mentioned, that irritation in the stomach and bowels 
is a frequent cause of epileptic paroxysms. Some individuals seem 
to be born with very irritable mucous membranes; and I have seen 
several epileptics so constituted, that the irritation produced by a 
laxative medicine, or diarrhoea coming on without any assignable 
cause, occasioned a recurrence of epilepsy. A lady affected in this 
manner with epilepsy, was recommended by one of the most learned 
physicians of the present day, to use drachm doses of the powder of 
mistletoe, which she persevered in without any apparent benefit for 
some months; at last happening to pass through a country town, and 
being in want of a supply, an apothecary sent by mistake drachm 
doses of powdered oak-bark, which proved of more service than any 
other remedy she had previously taken. The only inconvenience 
experienced was the subsequent difficulty of getting the bowels 
opened without producing irritation. Since this case presented itself 



[EPILEPSY.] 581 

to my notice, I have used astringents several times in similar in- 
stances with apparent benefit. 

The ammoninret of copper has been much lauded in the treatment 
of epilepsy, as also the nitrate of silver. The latter remedy lias been 
pushed to an extent which would almost surpass belief were the 
facts not well authenticated. It has been given to the extent of from 
one to eight grains a day, for weeks, without producing any effect, 
except slight griping pains, which ceased when the preparation was 
conjoined with opium. I have seen only two cases in which the 
remedy had any beneficial effects; and it is remarkable that they had 
been under the care of the late Dr. Baillie ; the skin of both was 
changed from the natural colour to that of indigo, but they were 
cured of the disease.* 

[The experience of the French physicians presents some very con- 
tradictory results; hut the following note, which was communicated 
by M. Escpairol to M. Ratier, embraces such a mass of evidence that 
1 gladly insert it here. u The Salpetriere," observes M. Esquirol, 
"contains upwards of four hundred epileptic patients, and 1 have 
employed, but unsuccessfully, all the boasted remedies for that dis- 
ease. More than twenty female patients, of different ages, and offer- 
ing, for the most part, the most favourable chances of cure, have 
made use of the nitrate of silver in various doses, from half a grain 
to eight and even sixteen grains a day, during several months, with- 
out experiencing the slightest relief. In many of them it produced 
very severe gastralgia. Two facts have contributed not a little to 
make me abandon the use of this medicine : a young girl was the 
victim of jealousy; the menses were suppressed, and she became 
epileptic. She was put under the use of nitrate of silver for a 
year without advantage. Soon afterwards the catamenia were 
reestablished, and the epilepsy ceased, and the case was considered 
a proof of the efficacy of nitrate of silver: but she avowed, on her 
dismissal from tin: hospital, that she had never taken a single dose of 
the medicine, and thai [In; return of the menses was owing to the 
he had secretly mad': of a Btrong infusion of emmenagogue 
plants. Tin: second case was that of a stout woman who, before en- 
tering i!"'.' Sal p£ there, hail taken the nitrate of silver in considerable 
during two pears. She was brought to the hospital in a state 

of deplorable cachexy; vomited whatever she swallowed, and suf- 
fered excruciating pains in the stomach, sin- died ; on examination 
it was foutid that the inferior half of the mucous membrane of the 
stomach had disappeared, and then- were four or five perforations 
through the peritoneal coat. Latterly," contiuues M, Bsquirol, "I 
have, with much caution, tried on live patients the muriate (hydro- 
ehlorate) of silver, :»s prepared by M. Pelletter, hut without having 
obtained any positive result. I have observed that moral influences 
have a power over the hram of' epileptics sufficient to retard the pa- 
roxysms. Th'' hope of cure and confidence in a remedy may produce 

tbiseflect; and thus the first yeM 'hat I was entrusted with the cure of 

[• This appearai ' i : I >- iii itself ind alarming to the patient, 

..n entirely, bat by rery ilow degrees. Ik disappearance is said to be much 

accelernied by Uic free OSS of A solution of MJpertarlraie ol jioiash.] 
49 



582 [EPILEPSY.] 

epileptics, the patients, in the belief that I would adopt some effica- 
cious treatment, suffered much less frequently from their paroxysms 
than they previously had done."] 

Several patients have been under my care, who were able to pre- 
vent an epileptic paroxysm if they had time to apply a ligature 
tightly round the arm, the moment the aura epileptica was felt in 
the hand. This is a curious circumstance ; but I can testify to the 
truth of it. One of these patients was found dead, having, it is sup- 
posed, died in the paroxysm ; one end of a cord was in his mouth, 
and the other in the hand, showing that he had been attempting to 
apply it round the affected arm. 

The only disease with which epilepsy is likely to be confounded, 
is hysteria ; but it is a matter of very little consequence in actual 
practice ; it being the slightest cases of epilepsy about which there 
can be any doubt, when the remedies applicable to the one disease, 
are exactly those which should be employed in the other. 

Catalepsy is a form of epilepsy which ought here to be mentioned. 
There are generally no convulsions ; the patient remains for a shorter 
or a longer time insensible, deprived of the power of voluntary 
motion, remaining in the position in which the body happens to be 
placed at the moment of attack; or if an extremity be moved into a 
particular position by an attendant, there it remains. This form 
occasionally runs into the true epilepsy with convulsions. It is, 
however, a disease of very rare occurrence.* 

[Galvanism has, of late, been employed with great effect in the 
treatment of epilepsy and other spasmodic diseases. Even in that 
most helpless complication of epilepsy with congenital idiocy, I have 
seen the convulsions reduced to a tenth part of their ordinary fre- 
quency : in one instance they were almost entirely suspended for 
more than three weeks, in a patient who had previously suffered 
from two to five paroxysms daily. But on removing the galvanic 
influence, the paroxysms gradually returned in their accustomed 
frequency and force. In another case which was treated by Dr. W. 
B. Simpson, resident physician to the Philadelphia Hospital, the result 
was still more fortunate : the patient, a stout, middle-aged man, had 
been struck with lightning, after which he became epileptic; his con- 
vulsions recurring every day, but without affecting his mind in the 
intervals. The galvanic apparatus was applied in the usual manner 
— his convulsions became at once less frequent, and in a few weeks 
ceased to recur. He was soon after discharged cured. About two 
years afterwards this man again entered the hospital, asserting that 
his convulsions had returned : but during a lapse of several weeks, 
no such recurrence was observed ; and I could not help suspecting 
that the patient had reapplied for admission more with a view to 
indulge his indolent habits than to avail himself of medical aid. 

In those cases of epilepsy which are not complicated with idiocy 
or organic disease, in other words, those which depend on mere 
functional irritation, galvanism seems to promise more than any 

* An excellent article on Epilepsy, by M. Esquirol, will be found in the "Did. des 
Sciences Medicates ," but the most profound work on this subject, is that published by 
Baron Portal, entitled. " Observations sur la Nature et le Traitement de I'Epilepsie." 



HYSTERIA. 583 

other single remedial agent ; but to insure its good effects it must be 
persevered in for several weeks at a time ; and the interval between 
the removal and the reapplication of the plates, (except to clean 
them,) should not exceed one or two weeks. 

I shall not slop to inquire in what way galvanism produces its 
favourable effects. Dr. N. Chapman remarks, that " the hypothesis 
from which this practical expedient is deduced, supposes an undue) 
accumulation of electric matter in the brain, at the expense of other 
parts of the body, and hence the cure depends on equalizing the dis- 
tribution of it." — A negative point is, therefore, established as near 
the brain as possible, and a. positive one in some distant part of the 
body. To meet the first of these indications, a blister about an inch 
and a half* in diameter is placed on the back of the neck near the 
roots of the hair; and a similar application is made on the inner side 
of the leg below the knee, or to any other part of the extremities that 
may be more convenient. To the neck we apply, first, a piece of 
sponge cut Sal and thin, and moistened with water ; secondly, an- 
other piece of sponge of the same shape, and also wetted ; and 
lastly, over the sponge is laid the silver plate, which is kept in its 
place by adhesive strips. 

The distant or positive point, being also prepared, as just men- 
tioned, by vesication, there must be applied to this surface, a piece 
of sponge, as in the neck; over this a thin layer of muscle or of 
buckskin, (for either will answer, and the latter is the cleanliest,) and, 
upon the buckskin, the zinc plate is to be secured by adhesive strips. 
Each of the plates has a small perforation near the margin, to which 
a delicate silver wire is attached; so that, by this means, the com- 
munication between the two plates is effectually insured; the wire 
passing down the back to the hip, whence it is brought over the 
groin, ami so to the zinc plate at the inside of the leg. ''The ap- 
paratus thus arranged," says Mr. Mansford, " will continue in L-entle 
and uninterrupted action from 12 to 21 hours, according to circum* 

Tins last is (he longesl period that it can be allowed to go 

pnremoved : the bona require cleaning and dressing, and the Burface 

ot" the Etna becomes covered with a thick oxide, which must be 
removed '" restore us freedom of action : tins may be done by 

: ing Or polishing; but it will be better if removed twice a day, 
both for the greater security of a permanent action, and lor the 
additional comfort of the patient." 

li may here !"• added, thai galvanism has not only been success- 
fully used in epilepsy, but also m nearly all the neuroses, and espe- 
cially the protean forms of neuralgia.] 



BTSTSBIA. 

Htstbmj Is another disc tse of the nervous system, the nature and 

sent o| winch have not, in any degree, been explained. It is a dis- 

ea.se almosi exclusively affecting females; but males are not entirely 
[♦ In young children the arface may be considerably smaller.] 



584 [HYSTERIA.] 

exempt. I have myself seen several well-marked instances in gentle- 
men, apparently of very different constitutions and habits; but the 
attacks came on in all of them under the influence of depressing 
passions. 

Phenomena of hysteria. — The invasion of hysteria is sudden and 
irregular, sometimes periodical. In the slighter forms, the patient, 
without any assignable cause, bursts into a fit of weeping, which, 
perhaps, is soon followed by convulsive laughing, which may last 
for a few minutes; and before composure takes place, the patient 
gives several loud sobs. One of these fits may quickly succeed 
another, till the patient falls asleep. In more severe instances, com- 
plaint is made at first of pain in the abdomen or chest; a sensation 
is felt as if something were in motion in the abdomen, owing, pro- 
bablv, to flatus; it moves upwards, producing in the epigastrium a 
sensation of lightness and of suffocation ; and a feeling is experienced 
as if a ball were ascending to the throat.* The belly is tense; the 
surface is generally cold; the extremities exceedingly so. The 
countenance varies; sometimes it is red and swollen, or pale, and 
the features contracted ; the pulse is also very variable ; and in some 
cases, palpitations are violent and troublesome. 

In the more severe instances of hysteria, there are symptoms 
showing the existence of affections of the head and spinal marrow, 
indicated by spasmodic, and even convulsive affections of different 
muscles, particularly of the hands, face, jaws, and those connected 
with respiration; they are of the clonic kind. The pupils are di- 
lated ; and occasionally, the paroxysm has a very close resemblance 
to epilepsy, only that the insensibility is rarely complete, unless the 
attack be combined with syncope. Occasionally there is retention 
of urine, but for the most part, there is a copious limpid discharge, 
in either case attended by symptoms of ischuria. Sometimes the 
disease commences with shrieking, which may continue from time 
to time during the whole paroxysm, and often terminates in hiccup 
of the most violent description. In some cases, dyspnoea is a very 
urgent symptom. Dyspeptic symptoms often precede the attack ; 
and the bowels will, in general, be found in a very bad condition, 
with a tympanitic state of abdomen. 

Some diseases of a very aggravated nature seem to be ushered in 
with violent hysterical symptoms, and require a very experienced 
eye to form a correct diagnosis. In many cases, however, the symp- 
toms of hysteria do not take place till the patient is recovering. 
When the practitioner is in doubt as to whether any severe organic 
affection is going on, thus obscured, the patient should be seen at 
short intervals; and the treatment cautiously conducted in such a 
manner as to remedy and not aggravate the more severe malady if 
it exists. 

[Mr. Tate, in his Treatise on Hysteria, states that a diagnostic 
symptom of the disease is pain in the left side. " This," he observes, 
"is very peculiar: it is usually situated immediately below the 
left breast, in a hollow formed between the cartilages of the fifth, 

[* It is this sensation which has received the name of globus hystericus.] 



HYSTERIA. 585 

sixth and seventh ribs : it is generally so circumscribed that it may 
be covered by a shilling, and is of the gnawing kind."* Mr. Tate 
supposes this pain to be seated in the intercostal nerve ; and although 
the right side is not free from it, he has observed it in nineteen cases 
out of twenty on the left side. The same author states his convic- 
tion that the protean forms of hysteria are referable to irritation of 
the spinal marrow, especially of its dorsal portion, and originally in- 
duced by a disordered condition of the uterine function. 

Since my attention has been drawn to this subject, I have so re- 
peatedly noticed the pain under the left breast, as to believe with 
Mr. Tate, that it is characteristic of hysteric affections; and that 
these " never do occur without a combined error in the nervous sys- 
tem and the uterine functions."] 

Causes of hysteria. — It is rare to meet with this disease before 
the age of puberty, or after the period of life when menstruation 
finally ceases; in most instances, women are attacked during the 
time of menstruation; therefore, many have attributed the disease to 
the uterus. Girls of high passions, and those who have been over- 
indulged when children, are most liable to hysteria'; as also those 
who become impressed with strong religious feelings, unaccompa- 
nied by a sufficient share of common sense to guide them. Women 
very pregnant, and those who labour under the disorders of men- 
struation, seem strongly predisposed to hysteria. It appears to affect 
women of all constitutions— that is to say, those who are robust and 
plethoric, as well as the pale, weak and emaciated. Some attribute 
hysteria to ihe bowels; and there are not a few who consider it as a 
disease of the nervous system. Emotions of the mind, together with 
irregularity of bowels, seem to be the chief causes. My own opin- 
ion is, that it is a complicated disease, and that the supporters of 
these different pathological views are all partially correct. 

Treatment of hysteria.— This is difficult at all times, and a radi- 
cal cure in many cases almost impossible, unless we had the power 
of changing the temper, altering the disposition, subduing the pas- 
sions, and relieving the mental distresses of the fair sufferers. It is 
of great consequence, however, to attend to the bowels, and to im- 
prove the powers of digestion. The diet should be light and nourish- 
ing ; cold should l>e .avoided, and particularly coll feel ; exercise in 

the open air should be advised: and the patient's mind should lie 

gradually strengthened, by being directed to healthful and interesting 
pursuits; and much is to be done by a proper intermixture of inno- 
cent and rational amusement During B paroxysm, the stays and 

all light string! should be loosened, and plenty oi' air admitted into 
the apartment, and sixty drops of the apiritus ammonise aromaticus, 

or the same quantity Of volatile tincture of valerian, may I"' U'ivcil 

m a Mrineglassful of water, li the bowels are distended by flatus, 
laxative medicines will do much to produce its expulsion; these may 
he assisted by injections, containing half an ounce of tfre tincture of 

feet ids, 1 or a lablespoonful of the Bptril Of turpentine. Opiates 

• n } 

j» A i.ii enema of assafoetida, to id, is made bj 



586 CHOREA. 

are, in many cases, serviceable after the bowels have been fully 
opened. Bleeding has been strongly recommended, and is often had 
recourse to in this disease ; but in pure hysteria, it is scarcely ever 
justifiable. Bitters, and more particularly the sulphate of quinine, 
will be found very serviceable in restoring the functions of the sto- 
mach and bowels. Should the disease be found to depend on any 
of the disorders of menstruation, the case must be managed accord- 
ingly, as will be pointed out in a subsequent part of this volume. 
In severe cases, a mustard plaster should be applied over the whole 
abdomen, and an enema of very cold water is frequently serviceable. 
[When the disease can be traced to irritation of the spinal mar- 
row, counter-irritation should be established in the course of the 
vertebras, either by blisters or by tartar-emetic ointment. The latter 
is preferable, and should be employed according to the directions 
already given under the head of Spinal Irritation, p. 568.] 



This is a disease of the nervous system, characterized by sudden 
involuntary motions of various muscles of the body, without being 
necessarily connected with fever, or any severe constitutional de- 
rangement. The appetite is generally unimpaired, and all the func- 
tions natural, except that, in many cases, the bowels are observed to 
be unusually tardy. But after the disease has continued for some 
time, the general health becomes impaired, and the functions of both 
mind and body are at last undermined. It most frequently appears 
between the age of eight and fourteen, but has been known to occur 
later; and several instances have fallen within my observation, 
where the disease attacked individuals after the age of twenty-one, 
and in two cases between thirty and forty. The later in life the dis- 
ease appears, it is generally found to be comparatively more slow in 
its progress, and difficult to cure. Generally speaking, convulsive 
movements, or rather twitches of the fingers and muscles of the face, 
are first observed. The convulsive movements become, in time, more 
decided; strange contortions of the features take place; the disease 
extends to the voluntary muscles of all parts of the body, and fre- 
quently those of the lower extremities are so continuously excited, 
that the patient appears to be dancing. His walk is very unsteady, 
and he is most affected when he wishes most anxiously to control 
his actions. Another curious circumstance is worthy of being men- 
tioned, that, however violent the convulsive motions may be, they 
cease the moment the patient falls asleep, unless in severe cases of 
long standing. Articulation and deglutition are frequently difficult, 
more particularly the former. In young subjects, a more acute form 
of the disease is occasionally met with. The intellectual faculties 
are more impaired; the general health sooner gives way; the sto- 
mach and bowels appear much deranged, as is indicated by hard- 
ness, sometimes unusual softness and swelling of the belly, together 

rubbing up a drachm of the gum with four ounces of water, and administering the 
whole at a single injection.] 



NEURALGIA. 587 

with constipation ; the stools have a very offensive smell ; and there 
are sometimes evidences of the existence of the disease denominated 
tabes mesenterica. 

Causes of chorea. — The causes of chorea are very imperfectly 
known. The opinion broached by Dr. Hamilton, senior, that chorea 
depends on a collection of feculent matter in the bowels, is so decid- 
edly erroneous, that I need not say a word upon the subject. It 
attacks people of both sexes, more particularly children who are 
scantily fed, imperfectly clothed, and prevented from taking a proper 
degree of exercise in the open air. There can he little doubt that 
those of an irritable nervous frame are peculiarly the subjects of cho- 
rea, and it has some resemblance both to hysteria and epilepsy. 

Treatment of chorea. — This should consist in keeping the bowels 
regularly open, by means of mild but frequently repeated laxative 
medicines, never allowing a day to pass without producing at least 
two alvine evacuations. The diet should be light and nourishing; 
every indigestible substance should be carefully avoided. All means 
should be had recourse to which will improve digestion, if it be im- 
paired, and restore the general health. In the two instances which 
I have met with above the age of thirty, the functions of the slomach 
and bowels were much impaired. But, superadded to these, the 
chief existing cause in these cases was the abuse of ardent spirits. 
The occasional application of leeches to the head when pain is com- 
plained of, and the administration of a narcotic when there is much 
nervous excitement, will be found serviceable. Good effects some- 
times follow the use of the warm, at others that of the cold hath. 
The oxide of zinc, castor, and many other tonics and antispasmodics, 
have been at various times in high repute; but of these, the car- 
bonate of iron, in doses of two drachms four times a-day, will fre- 
quently cure, or relieve the patient in a remarkable manner. 



NKUUALGIA. 

Those neuralgic pains of which I am now to treat, are not produced 
by any appreciable Organic lesion; they occur in every part of the 
body, ami often return periodically, Tin.' disease is most frequently 
partial ; sometimes, though rarely, it is general, but is not necessarily 
attended by fever. The tic dohuretiX is a striking example of this 
affection ; it is generally classed as a surgical disease, but is more 
frequently relieved by medical than by surgical treatment. The 
bladder, the Btomach and bowels, and the heart* also, are liable to be 
affected with neuralgia. 

[♦ s ••• the chapter on Neuralgia ; and in addition in the evidence there piven of the 

nenralgic character "I angina pectoris il elf I ul.nl I y <| note lnt ' <'tirr<>b'irative senli- 

pmanoitbe Univei liyol Pennsylvania: " That the disease ia a 
specie^ ol oenralgia I am entirely persuaded, commencing, foi the most part, Id the 
peneumogastric nerve, and spreading in different directions, as other nerves may 

l?ed. The derangements of the heart ami other structures, with which 

It i mi ', I bold i" i incidences <>r effects, ami not the cause, 

since, among many ret ons which might !»■ adduced in corroboration of this, the 

undoubtedly prevailed Independently of such organic lesions, ami 
conversely, these have existed wiiqoul occasioning it. Cogently is Its neuralgic 



588 [NEURALGIA.] 

[Indeed, there is reason to believe that all the nerves of the 
cerebrospinal system, from their origin to their ultimate ramifica- 
tions, are more or less subject to this disease, and especially the 
subcutaneous nerves. But the most frequent seat of the intense form 
of the disease is the head and face, which is attributable, observes 
Dr. Bennett, "to the number and sensitiveness of the nerves in this 
situation, as well as their superficial arrangement; and perhaps, 
also, to their intimate connection with the sympathetic, and conse- 
quent susceptibility of impression from conditions of the abdominal 
viscera." But it is the trigeminal or fifth pair of nerves which is 
generally attacked, and each of its branches is almost equally the 
subject of this suffering malady. When the first branch is affected, 
the pain shoots from the supra-orbitar foramen, and radiates to the 
upper eyelid, the forehead and to the eyeball itself. This is called 
hemicrania or megrini. It is accompanied by intense pain, heat, 
throbbing, intolerance of light, and an abundant secretion of tears. 
When the second, or infra-orbitar nerve, is attacked, the pain extends 
from the corresponding foramen as a centre to the lower eyelid, alae 
nasi, upper lip, side of the nose, teeth, palate and antrum, and even 
to the tongue. The inferior maxillary nerve is the third seat of facial 
neuralgia, which commences at the anterior mental foramen, and 
extends thence to the teeth, tongue, lip and cheek of the correspond- 
ing side, the pain terminating, as is the case also with the other nerves, 
in the mesial line of the face. 

The cervical nerves do not escape; and of the intercostal, that 
running between the eighth and ninth ribs is most liable to suffer, 
particularly in women. The lumbar nerves are the centre of neu- 
ralgic pains of the anus, spermatic cord, scrotum and ureter, and the 
uterus and vulva in women ; and to this cause is attributable most of 
those pains which are called sciatica and lumbago. The muscles, 
generally, are subject to neuralgia, whence the painful and bruised 
condition of the limbs in the early stages of fever; the glands, the 
parenchymatous and membranous structures and the skin itself, are 
also the occasional seats of this disease, which thus invades every 
texture in proportion to the nerves that are supplied to it.] 

The most troublesome and most frequent forms of the disease 
which I have met with in practice, are those abdominal pains which 
affect women, more particularlyat the menstrual periods, which shoot 
down the thighs. They sometimes appear to begin in the back, and 
extend towards the abdomen, in which case the bowels are generally 
found obstinately constipated. The discharges by stool consist either 
of very hardened faeces, or of gelatinous matter, resembling half-di- 
gested worms; at other times, they have a frothy, yeasty appearance. 
Affections of the bladder frequently supervene, particularly if the 
attack comes on during the menstrual period. This affection is of 
a different nature from that which is called dysmenorrhcea. In this 

character sustained by the well-established fact of its proneness to alternate with 
similar affections in other parts, as sciatica, lumbago, tic-doloureux of the face, gas- 
tralgia, muscular spasms, paralysis, or at least a loss of sensibility in portions of the 
body." Lectures on the more Important Diseases of the Thoracic and Abdominal 
Viscera, p. 158.J 



NEURALGIA. 589 

disease the menstruation maj be copious, of a natural appearance, 
and not attended with pain. 

Causes of neuralgic pains. — Frequently unknown, and for the 
most part obscure. They may be occasionally traced to disorder in 
the organs connected with digestion ; and, in some instances, may 
probably be connected with disease in the spinal marrow, or in the 
nerves themselves. 

[Partial wounds of nerves, and especially, blows on those of the 
face, are among the immediate causes. So also are severe atmo- 
spheric changes, although these mostly act through decayed or sensi- 
tive teeth, checked perspiration, and sudden and violent emotions 
of the mind, acting on nervous constitutions. Diseased conditions of 
the brain, especially at its base, whether from effusion, chronic in- 
flammation, tumours, &.c, and lesions of the membranes of the brain, 
are also among the many causes of neuralgic pain.] 

Treatment of neuralgic pains. — In tic do/oureux, I have seen the 
knife used very often, and but seldom with permanent advantage. 
If the pain have left the part affected, it has attacked another nerve 
in the vicinity — a strong proof that the disease is generally more 
deeply rooted in the system than is commonly imagined. In the 
treatment of neuralgic atfeetions, proper regulation of the bowels, 
diet and habits of the patient, and avoiding exposure in cold damp 
weather, are all points of the utmost importance. Almost all tonic 
and narcotic remedies have been successively in great repute; thus 
we find that bark, iron, zinc and other tonics, as also opium, musk, 
cicuta, hyoscyamus, belladonna and stramonium, have each their 
advocates. If the pain be periodical, the use of large doses of quinine 
will generally be found to act promptly and efficiently, as in intermit- 
tent lever. In fact the doses requisite in the one are precisely adapted 
to the other. Many severe and longstanding cases have been much 
benefited by drachm doses of the precipitated carbonate of iron ; 
but to siiddue a paroxysm of pain, and produce a long interval of 
. i he set la live sol i UK tn of opium, «i ven in small quantities, (15 or 
80 drops,) by injection, or the acetate or sulphate of morphia, in doses 
of l-4th of a grain, every 3d or 4th hour, will be necessary. Several 
very bad cases of general neuralgia have fallen under my observa- 
tion, and these remedies were found beneficial after all others had 
failed. One case, in particular, may be mentioned: A gentleman 
who had been frequently liable to partial attacks, was seized with 
general neuralgia during ihe period when he was preparing for gra- 
dual ion. 1 1 in general health became much impaired; and not being 
acquainted with any medical man in particular, he sent for one of the 
emen whose lectures he was attending at the time, but who 
offended him very grossly by discrediting I he account of his suffer^ 
niL's.aiid by terming his complaint " a graduation sickness." After 
the lapse of a month or six weeks, I was requested by a family who 
were interested in his welfare to visit him. lie was much emaciated, 

had a pale and haggard Countenance^ and was almost worn out by 
pain and want ofrest. The disease was general, hut the part most 

severely affected was the neck, where the pain was so much aggra^ 
vated by the slightest touch, that he was obliged to sit with his neck 



590 [NEURALGIA.] 

and shoulders bare. He had almost abandoned the intention of gra- 
duating. After putting his bowels into proper order, I gave him, 
while suffering a very severe paroxysm of pain, a dose of the seda- 
tive solution of opium ; and in less than ten minutes he felt more 
relief than he had experienced for several months ; and by repeating 
the dose a few times upon the threatening of a paroxysm, he got rid 
of the disease, his health and strength soon recovered, he renewed his 
studies, and passed his examinations with considerable eclat. Since 
the publication of the last edition, the attention of the profession has 
been directed to the external employment of veratria, by Mr. Turn- 
bull, of London. Five or ten grains of the medicine are to be mixed 
in an ounce of lard or simple ointment, and a small quantity rubbed 
carefully on the pained part. I can speak with confidence of the 
relief afforded by this application in six cases of tic doloureux, but it 
did not perform a cure in any one. 

[Neuralgia is extremely common in the United States, and is sup- 
posed to be more so than in former years, merely because the disease, 
which was formerly confounded with rheumatism and gout, is now 
better understood. It appears, for the most part, in a strictly parox- 
ysmal form; though its first invasion is often marked by a frequent 
succession of short and feverish paroxysms, which, by perfect rest, 
mild aperients and diaphoretic anodynes, soon present longer and 
more perfect intermissions with less of the inflammatory character. 
The free use of quinine, in the manner above indicated, becomes 
now our first reliance ; and after the paroxysms are broken, the same 
medicine should be administered to the extent of eight or ten grains 
per diem, for three or four days in succession. This plan has, of all 
others, been most successful in my hands. But it has been remarked 
that neuralgia is often attended with fever, and sometimes the pain is 
of so intense and pungent a character as to be agonizing and intole- 
rable, and especially in the facial forms of the disease. Under these 
circumstances, local remedies become absolutely indispensable ; and 
of these, free leeching over or near the parts is our most effectual re- 
source. When the fever runs high and delirium or coma is present, 
bleeding will be necessary; but I have rarely met with examples of 
this kind. After local or general depletion, or independently of 
either, blisters behind the ears, or elsewhere in the vicinity of the 
pains, are of great service, but they should seldom be applied to the 
part itself, inasmuch as they aggravate the pain and distress. Direct 
local applications of opium or belladonna, in plasters, are highly bene- 
ficial. So also is the tincture of aconite, which, from its activity, 
should be applied by means of a camel's hair brush, or a soft sponge. 
The ointment of veratria is another resource : it is formed of one 
part of the alkaloid with SO parts of rancid lard, and is applied to 
the affected part. The iodide of mercury, as recommended by Mr. 
Scott, is composed of two scruples to an ounce of lard. 

During the intermission, all the tonics from both the vegetable and 
mineral kingdom are administered with various degrees of success, 
depending on the seat of the disease and constitutional peculiarities. 
Among these preparations are the ferruginous articles, and especially 
the protocarbonate of iron; which, as it tends to constipation, may be 



NEURALGIA. 591 

made into pills with rhubarb. Spirits of turpentine, in drachm doses 
two or three times a-day, has been used with advantage by Dr. Ben- 
nett. Free catharsis has been resorted to by some physicians, and 
even croton oil is recommended by others. We have already spoken 
of the external use of aconite. It is also given internally in dose of 
the eighth of a grain three or four times a day. 

I have faithfully tried every form of galvanism* and electricity; 
but, for the most part, with little advantage. The electro-magnetic 
apparatus, however, is the most convenient of all these appliances 
and, in my hands, the most successful. It should be resorted to at 
the very outset of the pain; and under these circumstances, I have 
known a solitary case in which the paroxysms, though they yet 
recur at intervals, are invariably removed or greatly mitigated by 
the electro-magnetism, provided no fever is present at the time.] 

In the affection to which I have alluded as occurring in women, I 
have seen considerable benefit from the occasional use of a draught 
composed of turpentine, with an equal part of castor oil, and con- 
joined with twenty or thirty drops of the sedative solution. One of 
the most potent measures, after the diet has been regulated and the 
bowels have been put into good order, is to produce, from time to time, 
an eruption on the abdomen or loins, by means of antimonial oint- 
ment. In an obstinate case which lately occurred, much relief fol- 
lowed the use of strychnia, in doses of one-twelfth of a grain, 
repeated four times a-day, till it produced imperfect vision, with some 
degree of headache ; it was then intermitted for a few days, and 
when resumed, was given only twice a-day. Some practitioners 
speak highly of cold bathing, while others do the same of warm; 
but I cannot say that I have seen either of them beneficial. Routine 
practitioners are too much in the habit of bleeding whenever the 
pain is severe, and of giving calomel or blue pill when the pain is 
referred to the right hypochondriac region. I have been consulted 
by individuals whose constitutions were injured by the frequent repe- 
tition of powerful remedies, and by some who never can regain the 
loss of blood, or recover from complaints thereby produced, and the 
too frequent use of mercurial preparations. 

About the year 181 8, Mr. William Wood, of Edinburgh, called 
the attention of the profession to a neuralgic affection winch he de- 
nominated painful * subcutaneous tubercle," and has lately published 
further observations and eases in the 3d vol. of the Transactions of 
the Medico-Chirargical Society. Bat as this is avowedly connected 
with an enlargement of the affected nerves, requiring surgical rather 
than medical aid, I will conclude by recommending the perusal of 
Mr. Wood's learned and interesting essay. 

[• Bee the remarks 00 Spinal ami (Janglionic Irritation, payo MSB.] 



CHAPTER V. 
APOPLEXY— PARALYSIS. 



APOPLEXY. 



Apoplexy is generally characterized by loss of sense and volun- 
tary motion, the patient continuing comatose for a shorter or a longer 
period. It is sometimes attended with convulsions, and frequently 
followed by paralysis of some part of the body. 

Phenomena of apoplexy. — To detail the varieties of apoplexy, 
with a view to make minute symptomatical distinctions, would be 
an endless and really an unprofitable task; and practical men are 
well aware, that at the commencement of the attack, experience does 
not enable them to tell whether the case is to be slight, terminating 
in recovery, or fatal. This is well exemplified, by observing the ter- 
mination of those cases in which the loss of sense and recollection 
exists only for a few minutes, and in which the recovery appears as 
complete as it is sudden ; yet, perhaps, in a few hours afterwards, 
coma takes place, and death soon follows. In my lectures, I usually 
divide apoplexy into two varieties: — 1. That in which no lesion of 
the brain has taken place, and after death no morbid appearances 
can be discovered. This has been called simple apoplexy. 2. That 
in which serous effusion, or extravasation of blood, is found upon 
dissection, and which has been termed extravascular apoplexy. 

Although this plan is open to many objections, yet I am disposed 
to adhere to it for the present. 

Apoplexy very rarely comes on without precursory symptoms, 
which, however, are sometimes so slight as to be disregarded. These 
are vertigo — headache — a sense of pressure applied to the head, and 
fulness, or a feeling as if the head were a great deal larger than 
natural — irritability of stomach— singing in the ears— occasionally 
impaired vision — double vision— some degree of deafness — impaired 
powers of articulation — weakness of memory and judgment, some- 
times slight incoherency — restlessness or lethargy — startings, and a 
weakness of the limbs, which gives to the patient a staggering gait, as 
if he were inebriated : these symptoms may take place with or with- 
out rigors. Should an individual complain of several of these symp- 
toms at any period of life, he may be regarded as on the very brink 
of a serious affection of the brain. If they occur in a person of a full 
habit with a short neck, the danger will be still greater; and if in the 



APOPLEXY. 593 

decline of life, it might be safely said that he is in immediate danger 
of an attack of apoplexy, although by care and good treatment the 
disease may be warded off for an indefinite period. 

The form of the disease which I shall venture to term the slightest 
is that in which the loss of sense and voluntary motion is very 
transient. It continues for a few minutes only, and leaves, perhaps, 
a slight paralytic affection of the muscles of the mouth; the patient is 
commonly thought by the attendants to have been only in a faint, 
from which he quickly recovered. The variety which may be called 
the most severe, is that in which the patient has for some time com- 
plained of some of the premonitory symptoms already noticed, is sud- 
denly seized with loss of sense and voluntary motion, accompanied, 
perhaps, by convulsions, the respirations being stertorous, the pulse 
weak and frequent, and the patient never recovering from the state 
of coma. In practice, we meet with every variety between these 
two extremes. 

During an attack, the limbs are generally flaccid, although occa- 
sionally some of the muscles may be found rigidly contracted; and 
in other cases, as has been already mentioned, general convulsions 
take place. The face is red, sometimes of a very dark colour; but 
occasionally it is pale and ghastly; the features are swollen, and the 
mouth, perhaps, drawn to one side. The respiration is sometimes 
stertorous, at others, not in the least so. The pupils are occasionally 
dilated; sometimes contracted, but almost always immovable. The 
pulse is sometimes full and slow, not exceeding thirty beats in the 
minute; at other times it is weak, easily compressed, and quick, 
beating, perhaps, one hundred and fifty in a minute. 

In those instances in which death does not take place, and no 
organic lesion is produced, the patient soon recovers some degree of 
sensibility and the power of muscular motion,* when it may be dis- 
covered that one half of the body is paralyzed: the pulse, if pre- 
viously slow, now rises to the natural standard; he then recovers his 
senses, perhaps very quickly, and look's about him with ;ui expres- 
sion ( .|' surprise ; he also gradually recovers Ins speech, although he 
may have difficulty in articulating. In some hours, these symptoms 
will be found much diminished; he will gradually recover the power 
of his limbs and in ten or twelve days, although weak - , he may be 
pronounced to be nearly well. Instead, however, of recovering sense 
and voluntary motion immediately, patients sometimes continue 
comatose for SOOA hours and then recover more or less quickly in 
the manner already staled, being, however, at times lethargic for 
several days. 

In other cases, the patients" remain much longer comatose, ami 

recover much more slowly, with some degree of loss of memory 

and of speech, which may be temporary or permanent, together with 

paralysis of one halt' of the body, or only of one limb, the use of 

which may be sithet never or partially restored. I have seen seve- 
ral cases m which both mind and body were permanently reduced 
to a state of childhood. 

In OthSl oases, patient! remain for months m a lethargic, paralytic 
50 



594 APOPLEXY. 

state, from the time of attack till death takes place, without the least 
appearance of amendment. 

The period between the first appearance of any symptoms which 
can be called premonitory, and the actual apoplectic seizure, varies 
much ; sometimes years intervene, at others, an instant after com- 
plaining for the first time of violent pain in the head, or of giddiness, 
the attack comes on. The period between the attack and the return 
of sense and voluntary motion, also varies greatly. The period be- 
tween the occurrence of the first symptom and recovery, is also very 
various. The intervals between the attacks are by no means uni- 
form; sometimes only a few minutes intervene; at others, hours, 
days, weeks and even years. 

Many people survive fits of apoplexy even when small effusions 
of blood have taken place into the substance of the brain, and so 
far recover as to be able to transact their ordinary business ; but it 
very frequently happens, that if the patient survive an effusion of 
blood for a few days, a new train of symptoms will be excited — 
symptoms produced by inflammatory action in the brain, or mem- 
branes immediately in contact with the effused fluid. 

Causes of apoplexy. — Apoplexy is said to be hereditary. It may 
come on at any age, but in the great majority of cases the age is above 
fifty; certainly it may be said to be a disease of the decline of life. 
The individuals most predisposed are those of a full plethoric sys- 
tem, who have what is called a stout frame and short neck. Full 
living, idleness, sedentary occupations, late hours and sleeping on 
soft pillows increase the tendency to this disease, together with every 
other cause which disturbs the balance of the circulation. Diseases 
of the blood-vessels of the brain lead to rupture of their coats, and 
the consequent effusion of blood; viz.: ossification of the arteries, 
aneurism,* and obstructions in the sinuses ; and it is also well known 
that hypertrophy of the heart sometimes produces apoplexy. 

Appearances on dissection in apoplexy. — On cutting through the 
scalp of persons who have died of apoplexy, a considerable quan- 
tity of blood generally issues from the incisions. On removing the 
calvarium, the membranes are sometimes observed to be very vascu- 
lar, with some fluid beneath the arachnoid ; occasionally, although 
rarely, blood is effused between the arachnoid and the pia mater, 
giving an appearance of ecchymosis; or the effusion may have taken 
place into some part of the substance of the brain. The parts which 
I have most frequently found affected are the corpora striata and 
the thalami nervorum opticorurn. The ventricles are sometimes 
found distended with coagula; and the cerebellum occasionally suffers. 
Effusion of a serous fluid, in greater or less quantity, is found in the 
ventricles. It, however, sometimes happens, that no morbid appear- 
ance whatever can be detected. 

In old apoplectics, who have survived many shocks, cysts are 
occasionally found, enclosing a clot of blood, or a fluid resembling 

* There is a splendid preparation in my museum, of one large and two small 
aneurisms of the sylvian artery; the largest of which, about the size of a hazelnut, 
burst, and a large effusion of blood took place with instant death. The patient was 
only 23 years of age, and the brain was very much broken down by the effusion. 



APOPLEXY. 5 g 5 

pus, and sometimes they are empty, the contents having probably 
been absorbed. Some writers have described an appearance which 
they suppose to be a cicatrix, an almost complete restitution of parts 
having taken place. Sometimes we find considerable portions of 
the brain surrounding the effusion in various stages of inflammation, 
either showing marks of increased action or complete ramollissement. 
On some occasions, most extensive destruction from inflammation lias 
been discovered in the substance of the brain, a remarkable instance 
of which is subjoined. 

A gentleman, aged 51, stout in make, plethoric in constitution, 
having a tendency towards obesity, and accustomed to full living, 
was found dead in his bed after having had eight or nine apoplectic 
attacks, some of which were succeeded by temporary paralysis. The 
fit which preceded that which proved fatal, took place seven or eight 
weeks previously; it was severe, with a pulse as slow as 30 beats in 
the minute. Medical aid was promptly obtained, and he was saved 
by timely loss of blood. Subsequently to this attack, he was able 
to transact ordinary business, and actually attended a public meeting. 
Nay, on the night previous to his death, he played for some time at 
the game of backgammon, and evinced his usual acuteness of mind. 
On examining the head, the apoplectic attacks and the paralytic 
symptoms of which this gentleman had so long complained found a 
very sufficient solution in the mass of disease within the brain. The 
dura mater was found to adhere round the corona with such firm- 
ness, that it resisted every attempt at separation without tearing, and 
the skull itself was rather more than usually dense. On the upper sur- 
face of the brain a quantity of serous fluid was effused ; while at the 
base both of the skull and brain, the blood-vessels were unusually 
numerous and full, giving an appearance of redness to the base of the 
skull not often to be met with. The principal arteries of the base 
were enlarged in size, and presented numerous points of ossification, 
as did also the minute branches in every part of the brain. The 
ventricles were found to contain a small quantity of fluid, and their 
who! rafl red and vascular. In the third ventricle, part of 

the thatami firmly cohered ; but neither here nor at the base of the 
brain did (he fulness of the vessels extend much beyond the surface. 
On cutting into the substance of the brain, the traces of much dis- 
ease and an evident softening became apparent, particularly in the. 
ganglions of gray substance called corpora striata and optic thala- 
mi, in which the softening had passed on one side almost into sup- 
puration; and several regular cysts were discovered, four on the 
righf side of (he brain, and three on the left ; but none of them were 

of large size; and although both hemispheres were diseased from 

about the centre of the middle lobes forwards, yet the right had 
Buffered considerably more than the other. Such anatomical evi- 
dence is rarely found of life having been protracted with the pre- 
ttion of intellect, nil the whole centre of the nervous system 
underwent such a change as thai described in the above ease. 

Treatment of apoplexy — Some routine practitioners will lie found 
invariably to bleed in cases of apoplexy, without reference to the 
period of the disease and the state of the pulse. I have little doubt, 



596 PARALYSIS. 

that valuable lives are occasionally lost, which otherwise might have 
been saved, by avoiding the lancet. If the pnlse be slow and strong, 
a happier result may be expected from venesection than if it be 
quick and weak. The feet should be put into hot water, in which 
mustard has been mingled ; the garments should be loosened ; the 
head shaved, and cold cloths applied. Active purgatives must be 
speedily administered, to be assisted by injections of turpentine, par- 
ticularly if there be evidence of flatulent distension of the bowels; 
and blisters are to be applied to the lower extremities. 

Should a patient be fortunate enough to recover from the immedi- 
ate effects of the attack, much may be done by subsequent treatment, 
to present a return of the disease. It is of vital importance to keep 
the bowels daily and freely open, to avoid cold feet and exposure to 
cold damp air. Regular hours and exercise are to be enjoined, and 
a seton in the neck will be found very beneficial. Frequent bleed- 
ing, whether by the lancet or by cupping, cannot be too strongly de- 
precated ; our business being rather to prevent plethora by the above 
means and by a proper regulation of the diet. I know no plan more 
likely to create constitutional distress, and to promote the quick for- 
mation of blood in the system, than frequently repeated bleedings. 
A great deal of mischief is done by keeping patients too long upon 
slops ; it is far better, in many cases, after the first danger is over, to 
allow a small quantity of animal food to dinner, and toasted bread 
or biscuit, in moderate quantity, for breakfast and tea, than to give 
them a general order to live on farinaceous food, which, after all, 
many will not long adhere to, or if they do, they will take a large 
quantity to counterbalance the quality of the food. Restriction 
should be made respecting the amount of fluid to be consumed in the 
course of the twenty-four hours; and in all cases, where valuable 
lives are concerned, and when the patients move in that rank of 
society where they can obtain every comfort and attention, it will 
be found of great consequence to regulate the quantity of food and 
diluents by weight and measure. All causes of anxiety should, if 
possible, be removed; the patient should sleep in a large well-aired 
room, upon a hair mattress; he should use the patent air-pillows, 
with the head and shoulders somewhat elevated. 



PARALYSIS. 

Paralysis appears to have been generally confounded with apo- 
plexy by the older writers, who thought apoplexy was a complete 
paralysis, and looked upon the latter as a partial apoplexy. 

This affection is a frequent result of apoplexy, as well as of in- 
flammation of the brain, and of disease of the spinal marrow; but it 
often exists without any apparent organic lesion. 

Paralysis has been divided into several varieties. 1. Paralysis of 
the nerves of motion, which take their origin from the anterior part 
of the spinal marrow ; — 2. Paralysis of the nerves of sensation, which 
take their origin from the posterior part of the spinal marrow; — 3. 
Hemiplegia, which implies the existence of paralysis in one-half of 



PARALYSIS. 597 

the body; — 4. Paraplegia, which signifies that the lower extremities 
are paralyzed; — and, 5. Partial paralysis, as of the muscles of the 
mouth or of an extremity. 

Paralysis of the motive powers may exist in very different de- 
grees; it may be complete or incomplete ; in the latter case the indi- 
vidual uses the affected limb awkwardly, and it sometimes feels 
weaker and heavier than the other. 

Paralysis of sensation may also exist in various degrees. Sensa- 
tion is scarcely ever altogether destroyed, but is rendered more obtuse 
than usual ; but in some instances of paralysis, the sense of touch is 
very acute, so much so as to be a source of considerable suffering to 
the patient. 

At all age individuals may become paralytic. I have seen several 
children born hemiplegic, and young subjects are sometimes attacked 
with the disease ; but it is more frequently an affection of advanced 
age, and of men than women. 

Phenomena of paralysis. — When palsy takes place without being 
preceded by apoplexy, it is not generally accompanied by marked 
disturbance of the vascular system, or of the respiratory organs. 
Frequently there are premonitory symptoms, similar in many re- 
spects to those which oftentimes precede apoplexy, and to a practised 
eye announce that a serious affection of the nervous system is at 
hand. We sometimes perceive weakness of an extremity or numb- 
ness, together with coldness; and occasionally there is violent pain, 
in a limb. I have known paralysis to affect many people who had 
been subject for years to violent headaches, sudden pains in the 
course of the spine, and tingling ill the extremities. As the disease 
advances the weakness is more apparent ; the patient easily loses his 
balance ; he always feels unsteady, and experiences increasing diffi- 
culty in going down stairs, and in walking on an inclined plane. By 
and by he is obliged to use a stick; at length he cannot walk with- 
out receiving support from an attendant; and at last he is unable to 
move from one apartment to another. 

Although the disease snmeiime.s approaches so slowly that I have 
known perfOfM t<> be seriously threatened lor years previous to the 
paralytic attack, yet at other times it comes on very suddenly. Fre- 
quently there ifl momentary insensibility, and the patient's mouth is 
found to be drawn to one side; or the disease may attack an arm 
or a leg; oi one-half of the body may be affected. Sometimes the 
patient becomes paralytic without any affection of the brain. Vio- 
lent cramps sometimes take place in the extremity, which soon after 
is found paralytic. The bowels are generally very torpid; sometimes 
the muscular powers of the bladder are paralyzed, at other times 
those of its sphincter; in the former case, the patient cannot expel 
the urine, m the latter it is passed involuntarily ; frequently the rec- 
tum is similarly affected. The pulse will be found in different stales; 

frequently quite natural ; but in the affected limb it is generally ob- 

Sd t" M weaker than in the sound one. The limb generally 
becomes emaciated, although, to the patient's feelings, it may be con- 
siderably larger than natural ; it is usually colder, although, in rare 
cases, it is found to be above the natural heat. The mental faculties 

60* 



598 PARALYSIS. 

continue in many cases of paralysis quite unimpaired ; in others, 
they are slightly affected, the patients being sometimes a little inco- 
herent, or they betray some weakness of judgment; occasionally a 
state which has been called second childhood is produced, and con- 
tinues till death. Of all the mental faculties, memory appears to be 
the one most frequently affected ; the names of individuals and of 
countries will be forgotten, while circumstances connected with them 
may be often alluded to by the patient, who will be found, in the 
course of conversation, to forget words ; and it is curious that the 
memory will be more perfect respecting transactions which occurred 
twenty or thirty years before than of those which took place during 
the previous day. These circumstances, together with the appear- 
ance of the patient, particularly the expression of countenance, 
which is frequently silly, too often give an impression to a stranger 
that his mental faculties are weakened or destroyed, and the more 
so if, as sometimes happens, the saliva be running out of the corners 
of the mouth, and his speech is affected. This is most important, as 
a will was lately made by a gentleman when in this state, which 
was afterwards disputed by the heir-at-law : all the witnesses who 
had frequent intercourse, and several who had occasion to transact 
important business with him, were able to swear that he was of 
sound mind at the time, and for some time after the will was exe- 
cuted ; whereas, on the other hand, some who only saw him occa- 
sionally, judging from his appearance, and the lethargy with which 
he was at those times affected, swore that he was neither capable of 
thinking nor of acting properly. 

Causes of paralysis. — There can be no doubt that paralysis of 
every kind and degree may be producei by disease in the brain and 
spinal marrow. It is, however, more frequently produced by dis- 
ease of the spinal marrow. Facts seem to prove that paralysis may 
be produced by disease of the nerves of the affected limb, without 
any lesion of the central parts of the nervous system; and I also be- 
lieve, from the effects of certain remedies, that the disease under con- 
sideration may be the consequence of functional derangement of the 
nerves of the part affected, as well as of the brain and spinal marrow. 
Too much sexual indulgence, and certain noxious and disgusting 
habits, occasion palsy, particularly paraplegia. 

Treatment of paralysis. — We should be guided, in the treatment 
of paralysis, by the duration of the disease and by the pathological 
condition of the body on which this symptom depends. If the dis- 
ease be recent, and the individual not weakened, blood may be 
drawn both generally and locally, care being taken not to carry the 
bleeding too far. Strong laxatives must be exhibited at first, at 
short intervals ; but subsequently, during the progress of the case, 
they are to be given at longer intervals, so as to produce one or two 
evacuations daily, keeping in mind, that in most paralytic affections, 
the stronger purgatives are required to produce even a moderate 
effect. Emetics have been recommended, but they should not be 
employed unless there are evidences of a loaded stomach ; little 
danger need be apprehended from any temporary increase of deter- 
mination of blood to the head which is supposed to take place in the 



PARALYSIS. 599 

act of vomiting. Frictions on the affected part, with or without 
stimulating embrocations, are said to be serviceable, as well as con- 
tra-irritation in the course of the spine, produced either by any of the 
ordinary rubefacient, or the tartar-emetic ointment; caustic issues, 
as recommended long ago by Mr. Pott, may be applied; or moxas, 
which have been much praised by Dupuytren and Larrey. Elec- 
tricity and galvanism have been used in paralytic affections; but I 
cannot say that I have ever seen them beneficial. Some employ the 
hot bath, and others the cold. If it can be commanded, the patient 
should sleep in a well-aired apartment ; and it is of great conse- 
quence to keep his mind amused without being fatigued. 

The mix vomica has been much employed of late years in para- 
lysis. It has been tried to a considerable extent in the hospitals at 
Paris; and there can be no doubt that it has occasionally done good. 
It is exhibited in the form of powder, and of spirituous extract; of 
the powder two grains, of the extract three, repeated from two to 
six times daily, constitute a proper dose for an adult. It has also 
been given in the form of injection. In some cases, a tendency to 
muscular contraction appears in half an hour after its administration; 
Bad it is curious that the sound parts remain unaffected. It is said 
to increase the appetite, and sometimes to produce stupor, with a 
feeling of intoxication, and in an over-dose, tetanic convulsions. 
Still more recently, the active principle of nux vomica, called strych- 
nia, has been employed. I have used both preparations in a number 
of cases, and as yet have seen only one case in which the nux 
vomica was decidedly beneficial ; it was increased in doses of from 
two to eight grains daily, and its use persisted in for several weeks. 
Of the strychnia, I have exhibited four or five twelfths of a grain 
daily in several instances; and in two cases, the drug seemed to 
produce spasmodic muscular contractions of the paralyzed limbs. 
The strychnia, m particular, is worthy of further trial, as in many 
cases which do not depend on organic lesions in the central parts of 
tlit- nervous system, it will probably be found very beneficial. 

Dr. Bardsley, (Manchester,) states, that he employed the strych- 
nia in some catei of paralysis with no benefit, in others with only 
partial advantage, but in the majority with complete success. He 
dered thai il may be an efficacious, though not a certain reme- 
dy in this affection.* Dr. Bardsley has given thirty-five cases — 
of which twenty-two were cured—ten relieved — in two it had no 
effect — and our patient left the hospital. 

♦ Hospital Facts and Observations, p. 38. 



CHAPTER VI. 



INSANITY — HYPOCHONDRIASIS — AND DELIRIUM 
TREMENS. 



INSANITY. 



This, I am aware, is a term of very extensive application. Under 
it, I mean to comprehend every alteration of the functions of the 
brain from a state of sanity, with the exception of the delirium 
which so frequently accompanies fever and intoxication, and hypo- 
chondriasis. 

There are many degrees and shades of insanity. Some persons 
may be affected with the most violent delirium and incessant raving, 
furiously threatening the attendants with destruction, wrong alike in 
their perceptions and reasoning faculties. Others may have some 
eccentricity, produced by an error of perception, a wrong impression, 
or some slight derangement of judgment. 

Cases are frequently met with in practice where there is diseased 
perception, with more or less derangement of judgment, or the 
former may exist without any such complication. For example, an 
insane person frequently perceives objects which do not exist, or he 
may see a post which his diseased perception transforms into a 
monarch; he will kneel before his majesty, deliver an address, and 
kiss hands ; every act as it is done at court will be correctly imitated. 
Nothing can be said to be wrong about the insane person, except 
the first erroneous perception; all his actions tally with the situation 
in which he supposes himself to be placed. We meet with others 
who take up an erroneous impression, the reasoning faculties being 
perfectly sound, so that a man may conceive that a minister of state 
has been guilty of some dereliction of duty. He will write upon 
the topic, make out charges against the individual, and reply to 
letters received upon the subject; and yet no one, upon reading his 
correspondence, or from conversing with him, could discover any 
error of reasoning, or any expression which would lead him to con- 
clude that he was insane ; nothing is incorrect but the first impression. 
In some instances, we meet with errors in the reasoning faculties 
which frequently lead men to ruin their fortunes, and bring an accu- 
mulation of distress upon their families by following out some castle- 
building speculation, the absurdity of which is too apparent to every 
one but themselves. In others, we can only discover a disordered 
state of the association of ideas, or a disproportionate emotion from 



INSANITY. 601 

the application of slight causes. On other occasions, we find indi- 
viduals believing the fancies of a wild imagination to be realities; 
they transform themselves into kings and peers, or fancy themselves 
reduced in circumstances, even to beggary. In other cases, complete 
fatuity takes place. 

These different states may be variously mingled and modified into 
endless varieties of insanity, as it is usually treated of in books; and 
the symptoms may be still more diversified by the degree of excite- 
ment or depression which co-exists, together with the peculiarities 
of constitution and the state of the patient's health. 

Insanity sometimes makes its attack suddenly; but, in general, it 
is slow in its progress, although decided in its precursory symptoms, 
which, however, develop themselves differently in different cases: — 
One patient shows elevation of spirits, speaks loud, is easily irritated, 
and some eccentricity of conduct is sooner or later observed; at last 
lie will be found to follow out some particular hallucination, which 
will occupy his thoughts more and more completely as the disease 
advances. Another individual will show depression of spirits ; he 
will be observed to be more cautious, timid or shy in his manner; 
he thinks he hears the voices of individuals planning his destruction, 
or robbing him of his property; or his depression of spirits may be 
owing to religious doubts as to his own worthiness, or to the exist- 
ence of a future state; or he fancies himself haunted by evil spirits. 

We sometimes meet with an intermediate condition, where an 
individual shows his ordinary state of temper and disposition; he 
evinces neither increased excitement nor depression; while an erro- 
neous notion, religious, political or professional, haunts his imagina- 
tion for weeks, months or even years, which shows itself occasion- 
ally, but never disturbs his health, or alarms his friends, (ill some 
accidental circumstance gives the mental disease activity, when it 
breaks forth in a most decided manner. 

Son].' individuals show a great desire to quarrel, litigate and to 
take personal revenge for imaginary insults and injuries-, but all these 
propensities may exist separately:— A man may In; extremely quar- 
reisome, but, if properly managed, easily appeased, ami may never 
my tendency to take the life of a fellow-creature, nor would 
In- do aay iIiiiil' to hurt him. Another will take revenge only in one 
way, by litigation ; while the third, hut happily this is the rarest case, 
would murder all and sundry in the most cold-hloodcd manner, and 

when under restraint, will glory in the thought of murders he has 
Committed only in Ins own imagination; or, in the most ingenious 
way, he will endeavour to excite hatred between his keepers, so as to 

induce the one to murder the other. Others show a most determined 
propensity to commit suicide, and sometimes follow it out with so 

much pertinacity, as to elude, al last, the vigilance of the must attent- 
ive keeper ; and, what is very curious, each will have his own reason 
for lie- BCL The vainly of one has received a Mow which has low- 
ered him in lie- eyea Of the world, and he destroys himself because 

he cannot lire dishonoured, degraded <>r oven laughed at. The fear 
of another induces him to commit the rush act, with a view of escap- 

ii tome evil spirits, or Of disappointing the machinations of 



602 INSANITY. 

some relatives who have conspired either against his peace, his life, 
or his property. I have known a few instances also of men com- 
mitting suicide, who could not survive the loss of a wife or child ; 
and it would appear that the act was committed under the impres- 
sion that their departed spirits were to be immediately afterwards 
reunited. 

Several curious circumstances quickly attract the attention of those 
who are in the habit of attending this unfortunate class of patients. 
1. A hatred of, or indifference towards those to whom they were 
previously most attached, because these are the individuals who, the 
maniacs suppose, have conspired against them, and have ultimately 
deprived them of liberty. 2. Their physical powers are frequently 
not at all affected. Thus a body of insane soldiers under confine- 
ment, not completely fatuous, will fall into the ranks upon the usual 
signal being given, and will perform a number of mechanical acts at 
the word of command, with nearly as much attention and precision 
as if they were sane.* 3. The natural functions are generally not 
materially impaired, unless it be in those cases where insanity super- 
venes upon some other disease, or is produced by an injury of the 
head, some organic lesion in the brain, or by long-continued indulg- 
ence in the use of intoxicating liquors; when there may be heat of 
skin, quickness of the pulse and a train of nervous and other symp- 
toms which need not, at present, be more particularly alluded to. 

Causes of insanity. — Unfortunately, there can be no doubt that 
insanity is hereditary, at least under certain limitations; but I believe 
it may be warded off for many years, and in some cases entirely pre- 
vented, by proper management; which principally consists in keep- 
ing all the functions of the body in a natural state, by diet, exercise 
and attention to the bowels, as well as by avoiding all excesses, keep- 
ing the passions under control, and the mind properly exercised. 
Gluttony and drunkenness are too frequently the causes of insanity, 
and particularly the latter in cases where no hereditary predisposi- 
tion can be traced. Individuals seem also to be more and more pre- 
disposed to the occurrence of insanity as age advances, it being rare 
before the age of puberty. Among the passions, love, " by which 
the young and tender wit is turned to foliy," may be particularly 
mentioned as a fertile source of the malady under consideration, par- 
ticularly in females. It is rare to meet with a case of insanity from 
this cause in men, for reasons which are too evident to require being 
mentioned. Intense and long-continued anxiety respecting the re- 
sults of extensive mercantile speculations, as also the pernicious vice 
of gambling, are frequent causes of insanity. It is likewise a disease 
which sometimes attacks females after parturition, and also when the 
predisposition is strong, during the diseased states of menstruation. 

♦ This I had an opportunity of seeing at Chatham, where a large establishment 
has been formed for the insane officers and soldiers of the British army. Fort Cla- 
rence is, I believe, exclusively used for this purpose, and the unfortunates there have 
the enjoyment of good air and exercise, are well fed, kindly used, and carefully 
superintended. Long may it remain a monument to the good feeling and benevo- 
lence which characterized his late Roval Highness the Duke of York, and to the 
zeal and exertions which Sir James M'Grigor has always displayed to increase the 
comforts of the British soldier. 



INSANITY. 603 

Appearances on dissection in insanity. — Nothing satisfactory 
has yet been discovered ; for although many organic lesions have 
been found in the brains of individuals who have died insane, yet the 
same lesions have been observed where no insanity existed, and in 
many cases of insanity, no diseased appearance whatever has been 
detected in the head. Hence, in the present state of our knowledge, 
I am inclined to attribute the various and ever-varying phenomena 
which occur in insanity, to functional disease of the different parts of 
the cerebral mass. 

So far for the symptomatica! description of insanity, which, in my 
opinion, teaches nothing of the nature and seat of the disease. But 
if it be true that the brain is a congeries of organs, that each performs 
a peculiar function, and if we admit insanity to be a disorder of 
function, then, indeed, there seems to be sufficient grounds to warrant 
my departing from the usual beaten track, and submitting to my 
readers a short account of insanity, founded upon the phrenological 
principle that the brain is a congeries of organs. According to Dr. 
Andrew Combe, in his able work on Insanity, insanity is not a 
specific disease, but a symptom of disordered action in the brain or 
organ of mind, and, like every other disorder of function, it may 
proceed from a variety of different states. The delirium of fever is 
one form of disordered mind, which is always viewed as a symptom, 
and so ought all other forms. The brain being to the mind what the 
eye is to vision, it follows that, just as vision is deranged by many 
pathological states of its organs, such as ophthalmia, iritis, cataract, 
&a, so may the mind be deranged by many states of the brain. 
The sufFerers on the raft of the Medusa became mad from starva- 
tion and exposure ; while many become so from excess, particu- 
larly in stimulants. The asylum at Milan is filled by lunatics from 
bad feeding, and almost all recover by nourishing food ; while Bayle, 
at Charenton, finds many cases arise from chronic meningitis; 
and Broussais declares that, in the early stages, it is so obviously 
from inflammatory excitement, that it may often be cut short by free 
leeching, as certain as pleurisy is by blood-letting. Hence insanity 
is not the same disease in all. 

In mity, being a symptom of morbid action in the brain, springs 
naturally from causes affecting its health, ami hence a great affinity 
between the causes of acute cerebral affections, and of those on 
which insanity depends. The hereditary tendency depends on a 
peculiarity of nervous constitution, and is of primary importance. 
Excess "[' Borne mental qualities leading to eccentricity predisposes, 
in irritable constitutions, from the high action into which the cor- 
responding predominant organs are thrown; and hence the latter 
are generally those orhose manifestations are deranged, as proved in 
Diih, in by Sir. ('"mix! having, in SO many instances, pointed out 
correct \y,from development! tne probable form of the menial affec- 
tion. Other predisposing <-atiM's, such as age, sex, profession, &c, 

are referable to the same principle. 

The exciting causes are, whatever disorders the action of the 
brain. — That organ requires regular exercise for its health and pre- 
servation, and for the improvement of its functions, just as other 



604 INSANITY. 

parts do, as the muscles in fencing or dancing. Practice, in the latter 
instances, increases nutrition, and consequently, power, and it gives 
facility of combination to produce a given end. The same organic 
laws preside over the brain. Consequently, excess of exercise, as in 
intemperate study, excitement of passion, anxiety and strong mental 
emotion long sustained, leads to morbid cerebral action, with de- 
rangement of function in irritable subjects. Deficiency of exercise, 
or idleness, leads equally to diseased action and manifestations, as 
exemplified in the melancholy and ennui of the retired merchant or 
soldier, and in the numerous victims in the unoccupied classes of 
society. Local causes act by disordering the brain. Blows on the 
head, coups du soleil, intense cold, drunkenness, meningitis, &c, 
show this. 

Dyspepsia and other disorders of the abdominal viscera excite it 
secondarily in some instances in predisposed subjects, but, in general, 
mental causes have preceded. The same remark applies in nymph- 
omania and erotomania, in which the affection of the generative 
organs is generally the effect and not the cause of the cerebral dis- 
turbance. The brain, in short, is more frequently disordered by 
direct than by indirect causes, and, in this respect, the analogy 
between it and other organized parts is preserved. 

The symptoms indicative of insanity consist of deranged cerebral 
functions and local phenomena. Every sense, every nervous func- 
tion and every faculty of the mind may be involved in the disease 
or not, and hence indescribable varieties occur. The true standard 
is the patienVsown natural character, and not that of the physician 
or of philosophy. A person, from excess of development in one 
part of the brain, may be eccentric and singular in his mental mani- 
festations, and yet his mental health be entire. Before we can say 
he is mad, we must be able to show a departure from his habitual 
state, which he is incapable of controlling. An irascible man may 
be very boisterous without being mad ; but if a mild and timid 
creature become equally boisterous and irascible, we may fear for 
his wits. One may be naturally suspicious, jealous and cunning 
without being insane ; but if a man of an open, generous and un- 
suspecting nature becomes so, danger to his cerebral health is at 
hand. The derangement may consist in excitement of the patient's 
predominant qualities, in diminished action, or in perversion or 
vitiation of function. A proud man, who, during disease, fancies 
himself a king, is an instance of the first condition, or that of excite- 
ment of function; — one who humbles himself in the dust, and fancies 
himself unworthy of regard, is an example of the second, or dimi- 
nished function; — while one who fancies himself something out of 
the ordinary course of nature, is a specimen of perverted or vitiated 
function; — or one who is attached to friends when in health, may, 
when insane, either have inordinate love for them, be indifferent, or 
have a hatred and aversion to them; and so on with every feeling 
and faculty of the mind. 

The existence of digestive derangement modifies the mental state, 
and gives greater anxiety and irritability than when the stomach, 



INSANITY. 605 

liver and bowels act well. Other complications modify in other 
ways. 

Monomania, religions, erotic and other manias, are not different 
diseases. One organ or faculty being chiefly affected, and the rest 
entire, give rise to monomania; but the proximate cause may be, 
and often is, the same as when all the organs and faculties are affect- 
ed. Religions despondency is a mere symptom, also, and appears 
because the function of some cerebral parts is to manifest religious 
feelings, and those being sick, the function necessarily suffers, and the 
feeling is altered. But the same pathological state affecting comba- 
tiveness and destructiveness would produce furious mania. 

Monomania and melancholy are less easily curable, not from the 
proximate cause being more serious, but from the other faculties and 
reason succeeding in longer concealing the existence of aberration; 
whereas, in mania, it betrays itself early in spite of the patient. 

Insanity is not a state separated by a broad line from sound mind. 
Ev< ry gradation is observable, and we perceive morbid action be- 
fore; we can venture to say that the patient is insane. Some are 
cured at home of mental affections in a few weeks, who, if sent to an 
asylum, would become mad, and remain so for months or years. 

Treatment of insanity. — The first important question which 
naturally suggests itself in the treatment of insanity is, what combi- 
nation of circumstances ought to exist before a medical man is enti- 
tled to commit any individual suspected of labouring under it to an 
asylum, or to any other place, where he is not only deprived of his 
liberty, but is placed under some degree of restraint. This is a duty 
which I fear is still too generally performed without sufficient atten- 
tion to all the features of the case. Medical men should take care 
DO) Ollly to he themselves satisfied of the necessity of such a serious 
step, hut that they have sufficient proof, which cannot fail to convince 
a jury that it was most necessary. If an insane person evince a pro- 
penaity either to take away his own life or threaten that of another 
there can I ie no doubt that confinement is absolutely necessary. If 
an individual, in a state of mental aberration, disturbs the public 
; is a source of annoyance to anyone, a medical man, if 
. shou d recommend, as a preliminary step, the interference 
of the local authorities. If a patient act in such a way as to offend 
public morals, he being insane, or even eccentric, I also think an ap- 
peal should, in the first instance, be made to the same source for pro- 
lection. If a person he unable to manage his own affairs, if he enter 
into SUCh speculations as none hut a madman would think ol uuder- 
laking, which must he connected with some striking aberration of 
mind, or if he squander away Ins money, as in buying ;» pact of 
hounds, or expensive paintings, which neither his fortune nor his rank 
in hie entitle him to do, a medical man, consulting his own safety 
and the respectability of his character, will take care thai he is able, 
by the evidence of a sufficient number of disinterested witnesses, to 
prove the fact to the satisfaction of judge and jury before he signs 

the committal Of any lunatic. 

\ in hi may be perfectly mad on one point, and vet he quite able to 
manage his own affairs. Thus he may suppose thai Ins legs are made 

51 



606 INSANITY. 

of glass, and that if he attempted to stand, they would break into a 
thousand pieces. A second may fancy, that if he attempted to pass 
through a door, he would be crushed to pieces; a third may imagine 
himself to be a king; and yet they might all be able to manage all 
the transactions of ordinary life, and be wrong upon no other point. 
Surely it would not be justifiable in any medical man to commit such 
patients to a mad-honse. Individuals are frequently under some 
religious delusion, which may be quite innocent in itself, either as 
it relates to the individual, or the public at large. One man may 
fancy himself to be of divine origin; another may be in constant 
communication with angels and holy spirits ; and a young lady may 
innocently enough employ herself from morning to night in writing 
love-letters to angels; and yet a medical man would not be entitled 
to send them to a mad-house, unless public decency were offended; 
indeed, were it otherwise, the one-half of the world might be for 
committing the other who think differently on religious matters. 
Perhaps there are more religious than any other class of lunatics; 
and at present, there are a dozen or two of young ladies, who are too 
well fed, and have too little to do, praying by detachments, night and 
day, for the conversion of some of the highest, the most pious and 
the most rational members of the Scotch church. There are others 
who, in the wildness of their diseased imaginations, fancy that a pro- 
clamation for a universal pardon, alike to saint and sinner, has been 
received from heaven ; and that a power has been imparted to them, 
in virtue of prayer, to perform miracles ; in short, that they can make 
the lame to walk, renew the lungs of consumptive patients, and even 
raise the dead! Yet I suppose they consider themselves perfectly 
sane, and would be very much surprised to find themselves safely 
lodged within the precincts of an asylum ; but it would not be difficult 
to show, that they, as well as the followers of Joanna Southcote, and 
sundry other wild enthusiasts, are at least not very wise, and that a 
few weeks' work on the treadmill, with scanty fare, would probably 
cure them of such fantasies. 

The second point of importance is, should an insane person be 
sent to a proper establishment, or treated at home ? After consider- 
able experience in the treatment of insanity, I am disposed most 
unhesitatingly to declare, that removal from his own house, if not 
actually necessary, is the step best calculated to produce a speedy 
recovery, and more particularly if he be the head of a family ; it 
being the most difficult thing to gain a sufficient degree of authority 
over a person in the house where he has been always obeyed. But 
I entertain great abhorrence at the idea of consigning any person to 
a private mad-house, where the money received for board and medi- 
cal attendance is an object to the individuals who keep the estab- 
lishment. In a case where the liberty of the subject and the peace 
and happiness of so many individuals are at stake, should not pri- 
vate mad-houses be put down by law? Although, then, a decided 
preference should be given to a public establishment, yet I am not 
prepared to say that they might not be improved; and if an investi- 
gation were instituted by Parliament, it would be discovered, that 
the duties which the directors of such institutions take upon them- 



INSANITY. 607 

selves, are generally very slovenly, and sometimes very imperfectly 
performed. It would also be seen, that secrecy is not sufficiently 
observed ; and that, in some instances, the medical appointments are 
mere jobs, every interest being sacrificed to gratify the caprice of 
some idiots who ought to be patients instead of directors. 

In the treatment, more is to be done by moral management, and 
by attending to the bowels, to the regimen, and to the temperature 
of the patient's body than by heroic remedies, such as bleeding and 
blistering, exhibiting digitalis, and persevering in the use of strong 
drastic purges. As to general bleeding, it is necessary only when 
there is considerable plethora, vascular excitement, determination of 
blood towards the head, or more especially signs of inflammatory 
action in the brain ; but local bleeding by cupping, should, if possi- 
ble, be substituted, unless the balance of the circulation be much 
disturbed, when the lancet must be used. In a considerable num- 
ber of cases, shaving the head, and the occasional application of cold, 
by pouring water in a small stream upon it for a considerable length 
of time, will frequently diminish excitement, and produce tranquillity, 
without having recourse to bleeding. 

Opiates have been so often found injurious, that by some they are 
laid aside entirely; but I imagine this has happened from their in- 
discriminate employment, as well as from the insufficiency of the 
doses. I have seen the best effects from the exhibition of eighty, 
and even a hundred drops of laudanum, repeated every third hour, 
in cases where there were great irritability and want of sleep, and 
where there were no marks of organic disease within the brain. 
Blisters are rarely serviceable, and they oftentimes irritate a patient 
till he becomes unmanageable. Large doses of tartar-emetic will 
sometimes be found useful, having a very powerful effect in control- 
ling the circulation, and keeping the bowels open. 

The moral treatment consists in obtaining complete power over 
the mind of the sufferer, if possible, without the application of any 
violent means. This can be effected only by studying his character, 
■Voiding argumentative conversation, and keeping a sharp look-out. 
that he may have neither excuse nor opportunity to aggress. In 
short, a soothing system, and frequent acts of indulgence, as rewards 
tor quietneM and good conduct, are highly conducive to recovery. 
The high and ferocious maniac, however, requires to be secured 
during the night, by means of Straps and strong gloves, which are 
fastened in a peculiar way, so that the patient cannot do himself or 
his keeper any injury; and during the day, to be confined in a large 
well-cushioned chair, which is fixed to the floor; and even here the 
soothing system is of decided advantage. The superintendents and 
keepers should possess great prudence and imperturbable tempera;; 
and are never, on any account, to be allowed n» exercise any harsh* 
. either in action or expression, towards a patient. In man] 
establishments, there is a chair fixed in a box, very much like a sen 

try-box, wlueh is whirled round with great rapidity by machinery; 
and I am told that it has been found 01 great BerVMe in those cases 
where- gnat violence exists with a considerable share of reason. The 
remedy has to be used only once; subsequently, the mere threat of 



608 INSANITY. 

it is quite sufficient to make the patient control himself. Every 
ward should be heated with warm air, which will render fires in 
the apartments unnecessary. Comfortable clothing and preserving 
warm feet ought to be strictly attended to. Unless a patient have 
fever, his food should be substantial, and at the same time nourish- 
ing ; a dinner of good roasted or boiled fresh meat should be allowed. 
A proper share of exercise in the open air is highly necessary; and 
nothing is more beneficial than a minute attention to a proper clas- 
sification of patients; yet I fear, from negligence and laziness, this 
is either much neglected, or very imperfectly and irregularly per- 
formed. In a receptacle for the insane, this last should be insisted 
on as a daily measure. The number of directors should be increased 
in each establishment, and two should be compelled, under a severe 
penalty, to visit the insane every day at the hour of dinner, to satisfy 
themselves with respect to the food when presented to the patients, 
both as to its quantity and quality, and to see that an individual, with 
some returning sense, is not horrified by the presence of others in a 
much worse state than himself. Some means should also be con- 
trived to allow the visits of friends as often as may be wished, with- 
out the patient's being aware of their presence. 

It often becomes a difficult matter to decide when a patient is in a 
fit state to be discharged, and return to his friends. If I might be 
allowed to insist upon any particular line of conduct, it would be, 
not to dismiss a patient till he has been for at least two months with- 
out showing any aberration of mind ; and it is even justifiable, before 
his dismissal is determined on, to converse with him touching the 
chord of his previous illusion. This should be done by the medical 
attendant, whose responsibility is great, who should be well remune- 
rated, and be chosen as much for his honourable and benevolent 
feeling, probity and straightforwardness, as for his zeal and talents. 
It would be, perhaps, an additional safeguard if this examination 
were conducted in the presence of a magistrate. 

In addition to these remarks respecting the management of the 
insane, the following valuable observations by Dr. Combe are an- 
nexed. "Besides what you notice with regard to treatment, every 
thing demonstrates that employment of the patient is not sufficiently 
studied. The brain loses its health from vacuity of mind, and yet 
we shut up in scores, in perfect idleness, men who, when well, were 
accustomed to a bustling and active life, and whom, at any time of 
their lives, idleness would have driven mad. Manual labour and 
occupation are also of immense consequence, and the moral influence 
of keepers and superintendents, acquainted with human nature, and 
interested in their avocation, is prodigious in producing quietude, 
and accelerating recovery, just from giving to the brain that healthy 
exercise which it requires. Lunatics retain a good deal of reason, 
even in their worst condition, and hence are more accessible to the 
influence of reason and example than might be supposed. In every 
point of view, it is best to act towards them with the same consist- 
ency, firm honesty and good feeling as if they were quite in posses- 
sion of themselves. They are quick in detecting deceit, and when 
once deceived, they never give confidence again. I mention this, 



HYPOCHONDRIASIS. 609 

because I differ from what once said to you on this subject, 

in having flattered D 's predominating vanity, and led him by 

it, and from what you said in accordance with his views. My expe- 
rience says, never advance a word which you cannot conscientiously 
stick by when the patient recovers, and you will retain your ascend- 
ancy. Do not thwart his delusion, but neither give it any counte- 
nance. Our friend is now satisfied I am right in this, and I have 
decidedly proved it in practice. Remove all provocatives and allu- 
sions to the morbid feeling or idea, and exercise the rest as much as 
possible on their own objects. 

" In subjects not delicate, and not beyond middle life, I find many 
who are greatly benefited by cupping and free and repeated leech- 
ing, followed by tepid bathing, and cold to the head while in the 
bath. Many, of course, do not require depletion, but it may be ad- 
vantageously used when the usual indications exist. General bleed- 
ing I know little of, and do not like it. After the irritability and 
excitement of the immediate explosion are over, a great deal of ex- 
ercise in the open air seems most useful in diminishing irritability, 
relieving the head, and procuring sound sleep; but if used too soon, 
it injures. The ordinary principles of pathology ought, in short, to 
regulate medical treatment, and adapt it to the state of the indi- 
vidual patient, for the latter is the only safe and successful plan." 



HYPOCHONDRIASIS. 

lii:-; disease, when severe, is synonymous with monomania, and 
might, very properly, have been comprehended under insanity. 

Hypochondriac symptoms affect two classes of individuals: — 1. 

Those whose ailments are only imaginary or functional; and, 2. 

whose complaints are produced by organic disease. The first 

class of patients embraces the idle, the wicked, the dissipated, and 

. in are brought np without a profession, who, when left to 

'.ii resources, know not bow to kill time. The minds of such 

are enervated from a want of due exercise of the [acuities 

they may actually possess, till at last tin: vital actions become weak- 

tmeofthe natural functions, particularly those performed by 

the Stomach ami bowels, may be impeded; at which time, should a 

frx-nd ill.', oi lb,: history of a disease fall in their way, they will 

immediately fancy themselves affected with the same disorder. Or 
they may have a hundred and fifty different complaints, and think 
they experience a thousand Btrange sensations and unaccountable 
feelings, till bodily disease is, in the end, engrafted on the mental. 
The organic disease acts upon the mind, producing a state which, to 

say the le&Sl of it, i^ far from One of san it y. Tb 1, primary disease 

may be functional or structural. If the former, the stomach and 
bowels will, in general, be found to be the parts at fault; and 1 have 
sometimes discovered, on dissection, diseased Btates of the liver, 
lungs, kidneys, bladder, heart, blood-vessels, and also of the brain 
and its membren 

I have been often surprised, while attending hypochondriacs, to 
51* 



6!0 HYPOCHONDRIASIS. 

hear the animated description they give of their feelings; and as one 
impression is driven away, another quickly appears in its place. 
They sometimes declare that they have no appetite, and cannot eat, 
while they may be in the very act of taking a hearty dinner. In the 
same way with regard to sleep; according to their own account, they 
never close an eye night or day, although it is well known that they 
sleep ten hours out of the twenty-four. Some of them never have 
any passage from their bowels, although they pass two or three 
evacuations daily: and, on one occasion, a lady told me that she had 
not a stool for thirty-eight years, and wished for something to relieve 
her, although her bowels were quite regular at the time! Now, 
surely persons cannot be said to be sane in circumstances such as 
these. Patients affected with hypochondriasis are not always in the 
same state ; perhaps, without any assignable cause, they become quite 
Avell, and again relapse; so that the disease is intermittent and irre- 
gular, until it acquires some duration and intensity, when it con- 
tinues, the patient becoming progressively worse. 

Causes of hypochondriasis. — These are to be detected in a more 
satisfactory manner, by studying the character of the individual, 
assisted by observing the phrenological development of the brain. 
The character of the individual will be found, in general, to be timid, 
either from having been weakened by previous bad habits, or in 
consequence of a total want of moral courage. Hypochondriasis 
almost never makes its appearance before the age of puberty, and it 
should be made extensively known, that it more peculiarly affects 
aged bachelors and old maids! 

Treatment of hypochondriasis. — Both classes of patients are 
objects of pity and compassion, and alike demand strict and decisive 
medical treatment. We should never have any doubts, nor should 
we attempt to persuade a patient that he has not the disease which 
he supposes himself to labour under. Our language should rather 
be, that we possess a remedy which will most undoubtedly effect a 
cure; and we should use every exertion to inspire the sufferer with 
hope. To all patients we should be regular in our visits, and guarded 
in conversation ; but more particularly so when attending a hypo- 
chondriac. The bowels should be kept open; the diet should be 
regulated according to circumstances ; and, if the patient labour 
under local disease, it should be treated accordingly; contra-irritation 
produced by frictions with antimonial ointment, will be often found 
beneficial, as well as the occasional use of warm and cold bathing. 
Air, exercise, and every kind of innocent amusement, should be 
strongly urged ; and the physician should take the trouble to ascer- 
tain that his directions are properly followed; but he must not be at 
all surprised, or put out of temper, on finding that the patient, if 
wealthy, is in communication with twenty other medical men. 



DELIRIUM TREMENS. 611 



DELIRIUM TREMENS. — MANIA A POTU. 

Whenever a person has delirium, accompanied by a tremulous 
motion of the body, or even of a part of the body, he is said, in 
common language, to be affected with delirium tremens. 

[This affection occurs in drunkards, who, after a long indulgence 
in spirituous potations, are suddenly deprived of their habitual sti- 
mulus. The symptoms are extremely varied, from simple nervous 
tremors with aberration of mind, to the most violent and uncontrol- 
able mania: but, in a majority of cases, we are able to recognize the 
three stages mentioned by Dr. Blake, viz: 

The first stage appears soon after a protracted debauch, and is 
marked by slight fever, nausea or vomiting, cold, moist skin, great 
debility, vertigo, loathing of food, melancholy, and broken sleep 
with frightful dreams. After a few days follows the 

The second stage is characterized by utter sleeplessness, anxious 
countenance, constant tremor and delirium, extravagant hallucina- 
tions, incessant talking, and a violent and menacing manner. The 
pulse is frequent and full; the face flushed; the tongue dry and 
furred, and the pupils contracted. The bowels are mostly costive, 
and tlte evacuations, when induced, are olfensive. This stage lasts 
from three or four days to a week, yet seldom so long as the latter 
period. 

The third stage is sometimes a mere subsidence of the second : the 
patient drops into a deep sleep, and awakes convalescent. If, how- 
ever, the disease goes on, the mind continues maniacal, with in- 
voluntary struggling; a cold, clammy perspiration, a frequent, weak 
pulse, and universal tremor; and the patient dies either in a coma 
or convulsion. 

It must be acknowledged, however, that, in very many instances, 

in: not manifest; the symptoms being so confused as to 

admit of no demarkation. Patients sometimes go through the first 

nrithoul encountering the second: many, again, escape the 

third stage; wink in other instances, the disease begins with those 

symptoms which arc characteristic of the Beeond stage.] 

Two pathological conditions of the hotly are often confounded by 
practitioners, as well as by writers, under this term. The one is 
delirium, accompanied with trembling, the consequence of the com- 
bined influence of irritability and general functional disease of the 
nervous system, with positive weakness of the whole frame. In the 
Other, similar symptoms exist, with irritation and increased action, 
sometimes inflammation of the brain, the patient having a robust, 
perhaps plethoric, at all ei i nti an anweakened state of body. Both 
are- tie- consequences of ezee live indulgence in Btrong potations; 
hut a distinction between the two is, in general, not very diilicult, if 
D depend upon the history given of the patient's previous 
habits, by comparing these carefully with the immediate cause of 
the attack, and the existing symptoms. If we are told that tho 



612 [DELIRIUM TREMENS.] 

patient has had many similar attacks, has been long addicted to the 
excessive use of ardent spirits, and that the immediate cause of his 
present condition is great excess ; if he display no great bodily 
strength; if his pulse be frequent and weak, his tongue dry and 
dark-coloured, with a pale, subdued countenance, a different line of 
practice ought to be pursued from that which I would recommend 
in a patient whose health had been previously unbroken, and who 
was not habitually addicted to drinking. If such a person as the 
last mentioned were seized with delirium and trembling after a soli- 
tary debauch ; if the delirium were furious; the strength greatly 
increased; the limbs being sometimes spasmodically contracted; the 
pulse of moderate strength, and not above 100; and particularly if 
the tongue were moist, depletion must be employed. Whereas, in 
the first case, the hope of recovery must depend upon the judicious 
and timely exhibition of stimulants. The kind of stimulants should 
be adapted to the rank of life and habits of the patient ; but upon 
the whole, wine is the best repeated in the quantity of a small glass- 
ful, every half hour in urgent cases, or every hour or second hour, 
according to circumstances; attention must be paid to the bowels, 
and opiates and blisters used, if necessary. A patient labouring 
under this form of the disease, would, in all probability, be destroyed 
by the loss of four ounces of blood. 

In the second variety, which has been quoted, if the disease has 
not existed long, a bleeding from the arm, in such quantity as the 
case requires, will be found highly beneficial; but should the disease 
have gone on for any length of time, the same objections which 
were made against bleeding in the former case are equally applicable 
to this. But instead of stimulating, we must trust to the exhibition 
of powerful purgatives, shaving the head, and applying cold to it, 
with sinapisms to the feet or blisters to the legs. In some instances, 
local bleeding will be proper, when that from a vein is totally inad- 
missible. The observations already so frequently and so pointedly 
made in different parts of this work, with respect to venesection, and 
the difference in the results to be expected from that remedy accord- 
ing to the period of the disease, need scarcely be repeated in this 
place. But it may be again stated, that bleeding is often a doubtful, 
and sometimes even a dangerous remedy in this affection, when the 
pulse is exceedingly quick ; say 130 or 140, and still more so, if at 
the same time the tongue be dry and parched; whereas, it is at least 
a comparatively innocent remedy, if the opposite states of the pulse 
and tongue exist. Considerable caution is also required in exhibit- 
ing opiates; if the patient be restless and watchful, an opiate can, 
at least, do no harm, and is often of signal service; but if there be a 
tendency to coma, an opiate will, in general, prove hurtful. 

[Delirium tremens is frightfully prevalent in the United States ; 
and the treatment adopted here differs, in some essential particulars, 
from that mentioned in the preceding paragraph. 

It is to Dr. B. H. Coates,* of Philadelphia, that we owe those 
pathological views which have led to a new and more successful 

[* N. Amer. Med. and Surg. Journ., vol. iv., p. 27.] 



[DELIRIUM TREMENS.] 613 

treatment of the disease, and of which we propose to give a brief 
abstract. 

Dr. Coates, after describing the well-known effects of alcoholic 
stimuli on the human system, observes, that delirium tremens is 
produced by habitual stimulation; but not until the stimulus itself 
is suspended. "The patient is suddenly interrupted in a long-con- 
tinued course of hard-drinking. What is then the consequence ? 
The tremulant fever abates or subsides, from the abstraction of its 
cause ; and the system immediately feels the want of its customary 
narcotic. It has been gradually changed, until the depressing agent 
has become necessary to the preservation of an approach towards 
health : without it the patient is unable to sleep, and his cerebral 
and nervous system are thrown into a state of the very highest ex- 
citement. Who can fail to perceive in this the production of an 
excess of activity, a superabundance of vitality in the brain and 
nerves, requiring the habitual narcotic to keep it down to the ordi- 
nary standard." 

A complete analysis of Dr. Coates's valuable paper cannot be at- 
tempted in this place; but I shall give, in his own words, the apho- 
risms deduced from his investigation. 

" 1. The disease is a delirium and not a mania; and this distinc- 
tion should be attended to, both for medical and legal reasons. 

"2. It consists in a heightened activity of the sensorium ; and this 
appears to arise from a generation in that organ, of an unusual vital 
power which is not, as in common, exhausted by the narcotic poi- 
sons habitually used. 

" 3. The delirium may be combined with many other diseases 
and injuries, situated in many different parts of the body. 

"•I. When violent, it obscures and renders imperceptible most of 
the symptoms of the coexisting disease. 

"5. It is doubtless necessarily accompanied, as all vital excite- 
ments arc, with an unusual amount of the circulation of the blood 
in the organ affected ; and is, from this cause, sensibly influenced 
by cups, blisters and emetics. It is not so far checked by emetics 
as to render these advisable as a leading means of cure. It is not 
Mlfficiently under the control of the general circulation to be cured 
by venesection, or to be sensibly relieved by it without such an ex- 
haustion as is highly dangerous to life. 

m >,. It is entirely and absolutely under the control of opium, al- 
though Ihe fevew and other diseases which are liable to accompany 
it are by no means so. 

" 7. it admits of very large doses of opium, which are not pro- 
dnctive, either ;it the time, or subsequently, of any injurious conse- 
quent^, provided they are not repeated after a tendency to sleep is 

evinced. 

The patient must tfeep or die There is no alternative. Yet 
the physicuui should personally watch the effect of very large doses 
of opium. 

•• ■». Then is no distinction of stages which need occasion a mo- 
ment's delay in resorting to opium. 

" 10. Purgatives are of no use in this delirium; but it is necessary 



614 [DELIRIUM TREMENS.] 

to prevent costiveness subsequently to the administration of opium. 
Purgatives may be necessary for diseases which exist at the same 
time ; but when this is the case, they are, m general, most advan- 
tageously postponed till after sleep has been obtained. 

"11. Gentle stimulants are frequently useful during the conva- 
lescence ; but these should not resemble ardent spirits ; and an excel- 
lent and efficient one is capsicum. Nor should any ardent spirits, 
unless indicated by peculiar circumstances, be given during the pa- 
roxysm." 

Without subscribing to all these propositions, I must acknow- 
ledge that they have very much governed my practice for a number 
of years at the Philadelphia Almshouse Hospital: and although at 
different periods, the emetic and depletory plans have been abun- 
dantly tried, the opiate plan has been attended with the most decided 
success. The opium is freely administered ; viz.: from one to three 
grains every hour until sleep is induced : and, in several instances, 
after in vain giving these doses for some hours, I have made the 
patient take a tablespoonful of laudanum at once. If, as Dr. Coates 
observes, the patient can be made to sleep, the chances are in favour 
of recovery. If, on the contrary, he cannot sleep, death is, in a ma- 
jority of cases, inevitable. 

A case that came under my care, during the past year, was that of 
an innkeeper, who, after several weeks of hard drinking, became 
violently delirious and unmanageable. I was called to see him late 
in the afternoon, and directed him four grains of morphia in solution 
(equal to sixteen grains of opium) to be given in doses of a large tea- 
spoonful every hour. He took it all by the next morning, but without 
any sensible effect. I then ordered him a teaspoonful of laudanum 
every hour. In the evening he had taken five doses, (more than half 
an ounce,) but in his delirium broke away from his family and came 
in person to my house. He was with great difficulty got home again, 
when I administered to him at 9 o'clock, p. m., a large tablespoonful 
of laudanum. At 12 that night he fell asleep, slept soundly until 
next morning, and, with slight intervals, through the whole succeed- 
ing day. This man, who had been in a raving delirium, haunted by 
robbers and contending with shadows, became quiet, conscious and 
reasonable, and was soon restored to health. 

This patient, therefore, took the equivalent of nearly fifty grains 
of opium in forty-eight hours. 

In this case, as is much my custom, the head was freely cupped, 
and after convalescence commenced, a strong infusion of columbo 
and quassia was freely administered for several days. Let it not be 
supposed, however, that opium will, in every instance, control this 
disease: all that I maintain is, that it will cure more patients than any 
other remedial agent. I have seen cases in which it was of no ser- 
vice whatever : and in some others, after it has been used to a great 
extent, the anodyne effect was not produced until the patient had 
been walked to fatigue in the open air; after which sleep and reco- 
very followed. 

When the head is greatly affected, especially in plethoric persons, 
a blister should follow cupping; and I have met with a number of 



[DELIRIUM TREMENS.] 615 

cases in which venesection was not only admissible but indispensa- 
ble. 

The danger arising from the sudden and entire abstraction of 
spirits is said to be counteracted, in the Boston House of Correction, 
by administering a strong decoction of wormwood, which is given 
freely. With, perhaps, one exception, (say the managers,) there have 
been no fatal consequences from delirium tremens since this practice 
was introduced.] 



IP»; 



PART VI 



DISEASES OF THE EYE AND EAR. 






CHAPTER I. 
GENERAL REMARKS ON THE DISEASES OF THE EYE. 



The eye is one of the most sensible and delicate organs of the 
body, and, from its situation and function, is liable to many accidents 
and diseases, the nature and treatment of which are now happily 
much better understoorJTthau formerly. It is my intention to avoid 
noticing the surgical diseases of the eye, and to confine myself en- 
tirely to the consideration of those strictly medical, which will include 
inflammation of the different tissues of which the eye is composed, 
and the lining membrane of the eyelids, together with the diseases 
of the optic nerve. 

In the last century, uneducated quacks were chiefly employed in 
treating diseases of the eyes, which was no doubt owing to the gene- 
ral ignorance which prevailed on the subject. In the present day, 
we find a class of well-educated men called oculists, who devote 
their time and attention exclusively to this branch of the profession. 
There can be no doubt that advantages are gained, both by the 
profession and the public, from a division of labour ; but every indi- 
vidual, whatever particular department he may choose to cultivate 
and practise, should have previously gone through a good general 
medical education. Many of the diseases of the eye depend upon a 
variety of constitutional causes, which must be understood before 
we can cure or alleviate the diseases which they produce. It is now 
generally admitted, that every individual in the profession should be 
able to treat the diseases of the eye with the same facility with which 
he can manage those of any other organ. The surgical diseases of 
the organ of vision are certainly more complicated, requiring a deli- 
cacy of hand and quickness of eye which many do not possess; 
but those which fall under the care of the physician are similar to 
f Other parts of the body, though at first, perhaps, somewhat 
more difficult to understand and treat. Students of medicine of the 
present day will have themselves to blame, if they undertake the 
onsibility of general practice without a competent Knowledge of 
tins robject, as at every chool of medicine in tins country, an estab- 
lishment especially devoted to di ea • of the eye exists, superintend- 
ed by medical men of eminence in this department I am happy to 
have tins opportunity of speaking in terms of high commendation 
of the arrangements of tie; Eye Dispensary of Edinburgh, undei 
the able management of Drs. Robertson and Farquharson. 



620 GENERAL REMARKS ON 

The Germans are exceedingly and needlessly minute in their classi- 
fication of diseases of the eye. According to Plenck's arrangement, 
there are one hundred and nineteeen genera, and very nearly six 
hundred species. Dr. Mason Good, in noticing this division, observes: 
« A regard to our own ease may dispose us rather to take with the 
abbreviating spirit of Dr. Cullen than the discursive genius of Dr. 
Plenck." I think that a regard not only to our own ease, but to the 
ease, comfort and safety of our patient, ought to induce us to do so ; 
as it is scarcely to be believed, that any practical man can carry in. 
his head the one-hundredth part of the distinctions of the Germans. 

Inflammation of the eye may be divided into external ophthalmia, 
or inflammation of the conjunctiva in its principal modifications ; 
and deep-seated ophthalmia, or inflammation of the other tunics, in- 
cluding the disease called amaurosis, which, although not always, is 
sometimes produced by inflammation. These are subdivided into 
acute and chronic inflammation of the part affected. 

I shall now give a general but brief account of the phenomena of 
inflammation of the eye, its causes and treatment, before proceeding 
to consider the individual diseases. The general symptoms differ little 
from those of inflammation in other parts of the body, and only in as 
much as they undergo modifications from the peculiar structure and 
functions of the organ. Inflammation of the eye may be confined to 
one tunic, whence it often extends to surrounding tissues, and may 
spread in this manner till the whole organ is affected; or it may attack 
the whole eyeball at once, although this must be an extremely rare 
occurrence. The disease may be confined to one eye, or may affect 
both simultaneously ; or first one eye, the nthe other may be affected. 
Almost universally the disease attacks the same tissue in each eye, 
whether it be the iris, the conjunctiva, or the retina. Inflammation 
affecting one particular tissue of the eye, whether it be of an acute 
or chronic character, if not invariably, is generally characterized by 
some peculiar symptom or appearance ; thus, inflammation of the 
conjunctiva may be readily distinguished from inflammation of the 
retina, and both from that of the iris. 

Symptoms of inflammation of the eye. — These may be divided 
into local and constitutional. The local symptoms are, first, a sensa- 
tion which would be produced by a grain of sand in the eye, followed 
by a sense of heat and pain in the eyeball, increased secretion of 
tears, intolerance of light, and a feeling as if the eyeball were swollen. 
On making an examination, a network of vessels transmitting red 
blood is seen, although in a state of health they contain a colourless 
fluid. If all these symptoms be present, and continue for any length 
of time, no individual, however uninformed, can be in doubt respect- 
ing the existence of inflammation. But it often happens that very 
severe inflammation of the internal parts of the eye may be going 
on without any external redness or unusual vascularity; and cases 
occur which terminate in the total destruction of vision, unaccom- 
panied by much pain. Thus, Dr. Robertson was called to a case, 
some years ago, in which both eyes were completely disorganized 
within twenty-four hours from the commencement of the inflamma- 
tion, and yet the patient complained but slightly of pain. Intolerance 



THE DISEASES OF THE EYE. 621 

of light is not always complained of in an external ophthalmia, at 
least at the beginning of the attack, in proportion to the intensity of 
the inflammation, but it is a prominent symptom of inflammation of 
the internal parts of the eye. Instead of an increased flow of tears, 
a preternatural dryness of the eye may take place, particularly when 
the diseased action is intense. Swelling of the eyelids takes place 
when the inflammation attacks their lining membrane; they then 
sometimes become very much tumefied, which is by no means an 
unfavourable symptom. 

The observations which have been so often repeated in this work 
respecting other inflammatory affections, viz.: that symptoms vary 
much according to constitutions, and that an important organ may 
be undergoing considerable changes of structure, without producing 
the regular train of symptoms, either as to number or intensity, apply 
equally to ophthalmia. 

Severe inflammation of the eye is frequently attended by head- 
ache, nausea, prostration of strength, constipation and febrile symp- 
toms. When the internal coats of the eyeball are inflamed, there are 
generally more pain, headache and fever than in conjunctival inflam- 
mation. These are termed the constitutional symptoms. 

Causes of inflammation of the eye. — These causes are nume- 
rous and diversified ; few can be said to be peculiar, the great majo- 
rity being such as are well known to occasion disease in other organs 
of the body. They may be divided into two classes: — 1. External 
or local ; 2. Internal or constitutional. Among the first are included 
sand, dust, lime, small insects, the irritation produced by tumours 
growing within the eyelids, and inversion of the eyelashes. Of these, 
the application of lime is the most injurious, from its well-known 
property of destroying the vitality and texture of animal tissues. In 
all of these cases a very minute examination of the eye should be 
made. Morgagni relates the case of Thomas IVfangelli, a relative 
<>i ins own, who had a dangerous and protracted ophthalmia. His 
ins and surgeons believed thai an ulcer had formed in tin; 
cornea from inflammation, and a variety of internal as well as ex- 
ternal measures were adopted, bnl without the least advantage, until 
oip- of the mrgeons discovered the wring of a small fly in the bottom 
of what hid previously been considered an ulcer. The patienl re- 
collected dial an insect had flown into tin- eye a little before the 
inflammation commenced, and that it had been killed by the appli- 
cation (»i ins hand ; the wing had remained closely applied to the 
comei, where it brought on Inflammation, and the surrounding 
■welling represented the lips of a small ulcer. Soon after the foreign 
body wa> removed, the eys recovered. 

Acid fumes and vapours are fruitful sources of ophthalmia; as 

.also the application of gonorrhoea! virus, the discharge from a syphi- 
litic ulcer, or, indeed, acrid m itter "i" any sort. These are powerfully 
aided by intemperance. There can he no doubt of the influence of 
climate in producing inflammation of the eye: the colder regions of 
h I are comparatively exempt from these diseases, while they 
are fn queni and peculiarly severe in warm countries. Many writers 
« this circumstance, by attributing it to heat, light 



622 GENERAL REMARKS ON 

and dust. It cannot be disputed that any sudden exposure of the 
eyes to great heat or light is very hurtful to vision ; and, under all 
circumstances, long-continued exposure, without intermission, to 
light and heat, even when neither is very intense, must he injurious. 
Egypt appears to be the country which, of all others, is most favour- 
able to the production of ophthalmia. The English and French 
troops employed in that country, in 1801, were harassed by the 
general prevalence of the disease; and, in the subsequent expedition, 
the English troops were equally affected. Nevertheless, I am in- 
clined to believe that these causes are very much overrated, and that 
sudden atmospheric changes, and the disgraceful intemperance of 
British troops, have far more influence in producing inflammation of 
the eyes, not only in warm climates, but in our own, than is gene- 
rally admitted. It is not uncommon for ophthalmia to appear like 
an epidemic in this country during the spring and autumn months ; 
and it has been remarked to take place in seasons when there were 
considerable and sudden changes from heat to cold, more particu- 
larly if attended by moisture. In warm climates, these vicissitudes 
are more severely felt by the constitution. It will not require any 
laboured argument to show that these causes affect the eye by pro- 
ducing alterations in the balance of the circulation, and not so much 
in consequence of any direct effect on the eye itself. It is but fair 
to mention, however, that I have myself experienced considerable 
annoyance from the effect of light in warm climates, but not so 
much from the sun's rays falling upon the eye, as from the reflection 
produced by white sandy roads and white-washed houses, the sensa- 
tion being quickly removed upon getting into the shade, or walking 
upon grass. 

Among the constitutional causes may be enumerated general ple- 
thora, disordered state of the bowels, suppression of any discharge 
which had previously existed for a considerable time, including the 
constitutional discharges peculiar to the female, dentition, general 
chronic disease of the mucous membranes, the diseased state called 
scrofula, acute and chronic diseases of the skin, the retrocession or 
metastasis of inflammation to the eye during the progress of gout 
and rheumatism. 

Some of the most severe and intractable diseases of the eye take 
place during the decline of small-pox, scarlatina, measles, and other 
diseases of the same class, and constitute one of the numerous evils 
commonly denominated the "dregs" of these diseases. 

Treatment of inflammation of the eye. — After the sketches 
which have been given of the symptoms and causes of inflammation 
of the eye, it is necessary, in this place, to give a very short account 
of the remedial means ; but it must be premised, that some remedies 
are applicable to inflammation of one tissue, and some to that of 
another. Inflammation of the iris may be adduced as an example, 
in which the action of mercury is peculiarly beneficial. The treat- 
ment must vary also with the cause of the disease; if it be produced 
by acrid vapour, by the damp or exposed situation of the residence 
of the individual, or by particles of dust engendered during a person's 
trade or occupation, removal from the cause must, in general, be 



THE DISEASES OF THE EYE. 623 

insisted on before we can promise success. If any foreign body be 
lodged in the eye, it must be extracted; and this frequently requires 
some nicety, if it be imbedded in the coats of the eye, or in the 
cornea. Foreign bodies, however, most frequently lodge under the 
superior palpebra, and when their existence is suspected, the eyelid 
should be completely everted. Cases are sometimes met with, par- 
ticularly of slight inflammation of the conjunctiva, in which a spon- 
taneous cure takes place ; but as such a termination is doubtful, and 
always slow, we ought to pursue the proper course of treatment. 
Many cases yield to the application of warm vapour, warm anodyne 
fomentations, or astringent washes. These simple remedies, together 
with due attention to the bowels, and confinement to an apartment 
moderately lighted, will often have the effect of subduing the inflam- 
mation. Bui in severer cases of external inflammation of the eye, 
and in all deep-seated inflammations of that organ, more powerful 
measures must be used. Of these, general bleeding stands the 
(bremoat, and is more particularly indicated when the symptoms of 
inflammation run high — when the eye cannot bear a moderate light 
— and when there is a darting pain through the head. The indication 
is still more obvious, if there be fever with a hard pulse; and more 
particularly still, if the patient be plethoric. The quantity of blood 
drawn should be proportioned to the urgency of the symptoms, the 
age, peculiarities of constitution, and habits of the patient. The 
importance of general bleeding in many cases of ophthalmia, has 
been long known to the profession ; but like most of the potent 
remedies employed for the cure of this and other diseases, it has 
sometimes been held in great estimation, and at others sadly decried. 
It is now above thirty years since the disease called the Egyptian 
ophthalmia created such ravages in the British army, having the 
doable effect of crippling its exertions, and entailing a heavy ex- 
npon the nation, in the shape of pensions to soldiers who had 
lost their sight ; and when 1 first entered the army, in the early part 
of it] .1 oi ol erved sufficient to convince me, that 

1. 1 success was owing to injudicious treatment, particularly 
i four most essentia] points:— 1. The older military sun 
on whom the treatment devolved did not seem to be 
tainted with the different seats of the inflammation. I never 
toy distinction made by one old surgeon, whose wisdom and 
kiin .. nerally admitted and highly extolled, between 

inflammation of the conjunctiva and that of the iris; 2. It was 
i of surprise to find thai eyes were lost in the course of a day 
or two, when the symptoms were apparently mild, and they seemed 

t.. expect i" meet with B severe and rapid disease only when there 

violent symptoms, and the chief symptom they depended upon 

pain; S. They appeared to be unable to' discriminate between 

acute and chronic inflammation, which often led them to apply local 

; injudiciou . •. i. A great deal of bad success was 

owing to a systematic plan of taking from all subjects, whether old 

or young) weak or strong lined or plethoric, the precise 

ojoantity of twelve or sixteen ounces of blood. While acting under 

an old surgeon, the plan of treatment ordered to be pursued, when 



624 GENERAL REMARKS ON 

a man came into hospital, was— "Bleed him, sir, to 16 ounces, and 
give him salts." If the patient happened to be better at the next 
day's visit, an order was given to apply a stimulant, generally the 
vinum opii. On the following day, if lie were worse, (he order was 
— "Bleed him again, sir:" and this alternation of practice, — bleed- 
ing one day only to weaken the system, without making any decided 
impression on the disease, and applying local stimulants the next, 
before the acute inflammation was subdued — appeared a most 
decided error in the treatment. So strong was the impression made 
on my mind, that one day tiiree men were received into hospital, 
whom 1 was desired to bleed, and not considering, or perhaps dis- 
regarding the consequences of deviating from the regular plan, I 
bled each of them to syncope, which required the abstraction of 
from 25 to 35 ounces of blood. The men made rapid recoveries; 
but the transaction would have cost me my commission, had I not 
had powerful friends at court. 

I knew another surgeon, who, although he used to bleed in cases 
of ophthalmia, placed his chief dependence on Dover's powder. To 
show how much the government was alarmed for the state of the 
army, it may be mentioned, that a male and female quack were hired 
to take charge of the cases in a certain military hospital ; but, as 
might have been expected, their mysteries and mummeries failed 
altogether in checking the ravages of the disease. 

On a subsequent occasion, a medical gentleman joined the army 
with high pretensions as an oculist. He introduced the practice of 
everting the eyelids, which was done in all cases, for the purpose of 
applying stimulants: and I attributed the loss of a great number of 
eyes to the indiscriminate employment of this operation together with 
not distinguishing the difference between acute and chronic inflam- 
mation, as well as between superficial and deep seated inflammation 
of the eye. 

One bleeding will, in general, suffice, but it should be carried far 
enough to affect the constitution. Drawing blood from the temporal 
artery has been strongly recommended by many. I have seen it 
often practised, but was never sensible of any superior advantage 
derived from this method; and it may be mentioned, that some 
practitioners of reputation consider it rather injurious. The applica- 
tion of leeches is the most gentle method of taking blood from the 
vessels in the neighbourhood of the eye; they may be placed either 
upon the forehead, the temple or the cheek immediately below the 
eye. Some object to this means, because the leech-bites occasionally 
produce considerable swelling and inflammation of the eyelids, now 
and then assuming an erysipelatous character; but it should be 
recollected, that this will only happen in cases where there is a bad 
habit of body, in which circumstance their application may be avoid- 
ed. Cupping the neck may be had recourse to, either when leeches 
cannot be obtained, or when it may not be convenient or proper to 
employ them. In conjunctival ophthalmia, particularly when the 
lining membrane of the palpebra is vascular, the application of the 
scarificator to the everted lid will be found very beneficial, and is a 
speedy method of taking a considerable quantity of blood from the part 



THE DISEASES OF THE EYE. 625 

affected ; but it is only to be had recourse to in certain cases hereafter 
to be noticed. A modification of this last practice has been recom- 
mended by Mr. Crampton, (3d vol. Dub. Hosp. Reports,) which is, 
to apply leeches to the everted mucous membrane of the lower pal- 
pebra. 

The beneficial effects of the most judicious and copious abstrac- 
tions of blood will, however, soon be lost, unless followed by other 
important means, such as the keeping up a moderately brisk dis- 
charge from the bowels, and the use of antimony. Blisters, applied 
either to the neck or behind the ears, are often serviceable; and in 
cases of chronic inflammation of the conjunctiva, when the mucous 
membrane of the intestinal canal is in a state of great irritation, I 
have found it very beneficial to apply the tartar-emetic ointment to 
the abdomen, alternately with leeches to the epigastric region: it is in 
such cases that the frequent use of the warm bath proves beneficial. 

In acute and even subacute inflammation of the eye, the employ- 
ment of the antiphlogistic regimen is indispensably necessary; but I 
apprehend that practitioners too frequently run into an extreme, by 
persevering in the use of slops and low diet for too long a period, to 
the injury of the functions of the stomach. 

With respect to local applications, some practitioners have great 
faith in cold lotions of different kinds, and others in warm fomenta- 
tions, consisting merely of warm water, or its vapour, a decoction of 
chamomile flowers, or of poppy-heads. Whether the applications 
are to be warm or cold may be safely left to the feelings of the 
patient, although the former appear, in a majority of instances, to be 
most soothing. Poultices are used by many, but they are not so 
serviceable as fomentations; and if there be any tenderness, it is 
increased by the weight. In pustular ophthalmia, as well as in 
chronic inflammation of the conjunctiva and cornea, stimulants are 
most conducive to the cure, and perhaps the best is the vihum opii. 
I conditions, astringent washes arc also used in the proportion 

or two grains of the acetate, of lead, or suljihale of zinc, Or 
from one to seven or eight grains of the sulphate of alumina, to the 
ounce of water. A solution of the nitrate of silver is also employed 
in different conditions of the eye, as in chronic inflammation of the 
conjunctiva, and inner membrane of the eyelids, as well as in ulcer- 
ation of the cornea. Emetics have occasionally been found service- 
able in some long-standing cases of conjunctival ophthalmia. 

Experience has proved that the action of mercury is almost indis- 
pensable in inflammation of the iris; hut it is by no means to bo 
depended upon to the exclusion of general and local bleedings. 

ithstanding the general opinion which prevails againsl the 
administration of opiates in the diseases under consideration, 1 would 
strongly recommend them in cases 'where there are great pain, and 
want of sleep, after the employment of proper depletion. The 'luxe 
mutt be proportioned to the urgency of the pain, as well as to the 
of constitutional irritation; in severe cases, I have given, 
with benefit, 60 drops of laudanum, or 90 of Battley's sedative solu- 
tion; but in either case the dose should be repeated, with half the 
quantity, m the course of two or three hums, if necessary. 



626 GENERAL REMARKS ON THE DISEASES OF THE EYE. 

So long ago as the year 1807, Dr. Wardrop recommended the eva- 
cuation of a part of the aqueous humour, by making a puncture in 
the cornea, in cases of very violent inflammation of the eyeball, 
when the pain is intense, the eye prominent and the cornea slightly 
opaque ; and more particularly when the case appears to resist other 
treatment. I cannot speak of this operation from experience ; but it 
appears to have been performed, in a few instances, with benefit. 



CHAPTER II. 
INFLAMMATION OF THE CONJUNCTIVA. 



1. Simple inflammation of the external covering of the eye, includ- 
ing what is termed by authors ophthalmia mitior et gravior; 2. Sim- 
ple Catarrhal Ophthalmia ; 3. Purulent Ophthalmia, the description 
of which will be drawn from the disease as it occurs in infancy; 4. 
Pustular Ophthalmia. 



SIMPLE INFLAMMATION OF THE EXTERNAL COVERING OF THE EYE. 

The conjunctiva, from its situation, is, of all parts of the eye, most 
liable to inflammation. In the natural state, it is rare to see vessels 
carrying red blood, but on the slightest irritation the vessels of this 
membrane become injected. It is only in the most intense inflamma- 
tion, of some days' continuance, that we see vessels on the surface of 
the cornea. 

Symptoms of simple inflammation, 8,'C. — A sensation of itching 
takes place, sooner or later succeeded by pain, resembling that which 
is known to be produced by sand or dust when applied to the eye; 
redness heat, tension and throbbing follow, aggravated when the 
eye is moved, and upon the admission of light. An increased flow 
of tears is observed, sometimes scalding the cheek, or an unusual 
dryness of the eye from suppression of tears, which last adds greatly 
to the pain. In severe cases, the pain shoots from the eyeball, as it 
were through the head, or affects the scalp on the forehead over the 
affected eye. In sunn; instances, there are febrile symptoms, with a 
mil, stroii'.', bounding or hard pulse, generally preceded by rigors or 
slight chilliness. If the symptoms are mild, the disease is called oph- 
thalmia mitior; if severe, ophthalmia gravior. 

On examining the eye. m the acute stage of the disease, the vessels 
are observed t<> I"' superficial and distinct, running in straight lines, 
leaving the intervening spaces of a slight pinkish colour; and when the 
■mailer branches are also well injected with red blood, the conjunctiva 
has a uniform red appearance; whereas, when the disease is chronic, 
the vessels become tortuous in their course, assume a purple colour, 
and are capable of being rolled about from the looseness of the cou- 
necting cellular tissue. We judge also of the change in the character 
of the inflammation by the cessation of the severe throbbing pain, and 

by the greater tolerance of light. In some cases of the description 



628 INFLAMMATION OF THE CONJUNCTIVA. 

now under consideration, as well as in those of the affection which 
has been denominated purulent ophthalmia, the conjunctiva be- 
comes swollen, having a red, granular, somewhat fungous appear- 
ance, and considerably elevated above the cornea; this state is called 
chemosis, and is frequently confounded with ecchymosis, which also 
takes place occasionally, not only in chronic, but in acute inflamma- 
tion of the eye. Chemosis is occasioned by thickening and vascu- 
larity of the conjunctiva, with an cedematous state of the subjacent 
cellular tissue. We see, on some occasions, also, an accompanying 
oedema of the eyelids, which become much swollen, and occasionally 
a red fungous state of their lining membrane takes place. In these 
circumstances, there is some puriform secretion. 

Treatment of simple inflammation, $c. — In the milder forms of 
the disease, general bleeding is unnecessary; but if the complaint do 
not yield to other remedies, it would be wrong to delay opening a 
vein, particularly if the pulse be hard, or if there be much excite- 
ment in the system. In severe cases, one prompt and copious bleed- 
ing will be necessary, followed by the application of leeches, foment- 
ations, strong purgatives, the solution of tartar-emetic, and blisters, 
as the urgency of the symptoms may require. It is important to 
consider what the circumstances are which we have to dread; — 
puriform effusion into the cornea, together with opacity, thickening 
and ulceration; and the extension of the inflammation to other tis- 
sues. Chronic inflammation of the conjunctiva may take place in 
two different circumstances, viz.: either as a consequence of previous 
acute disease, or as a slow inactive inflammation. In either of these 
cases, the eye has the appearance formerly described ; and the prac- 
tice which I would recommend, is to pay more attention than is 
generally done to the constitution ; the condition of the mucous mem- 
brane of the stomach and bowels should be carefully investigated in 
the manner so fully pointed out in the first volume. In chronic 
inflammation, it may sometimes be found of great service to scarify 
the eyelids, if there is much vascular turgescence of their lining mem- 
brane; astringent and stimulating washes must be had recourse to; 
it is in these cases that the solution of nitrate of silver is found useful, 
together with the wine of opium and an occasional blister. It has 
been recommended to divide the trunks of the small vessels just before 
they enter the cornea, when there is any tendency to opacity, and 
when red vessels are seen on that part; and although it may be 
beneficial in some cases, yet I have seen it injurious in many, by 
producing additional irritation. 



SIMPLE CATARRHAL OPHTHALMIA. 

The particular affection which I wish to denote under this term is 
one of very common occurrence in this country, being the effect of 
sudden alternations from heat to cold; it is, in fact, called by the 
vulgar, "a cold in the eye," and, generally speaking, is to be consi- 
dered as a mild description of purulent ophthalmia, which disease, 
in its more aggravated form, is known by the appellation, Egyptian 



INFLAMMATION OF THE CONJUNCTIVA. 629 

opht ha! aiia— occurring after the application of gonorrhceal virus 
to the eye, gonorrhceal ophthalmia — and taking place in infants, 
infantile purulent ophthalmia. They are all the same disease, 
requiring the same treatment, modified by the patient's age and 
peculiarity of constitution, and by the urgency of the case. 

Symptoms of simple catarrhal ophthalmia. — After exposure to 
cold, soreness of the eye is complained of, either preceded or accom- 
panied by chillness and a feeling of general uneasiness, with lach- 
rymal discharge, sneezing, and sometimes aching pains in the bones, 
and some degree of fever. It is a slight inflammatory affection of 
the conjunctiva ; but the inflammation is, in some cases, so very great 
as to destroy the eye. In addition to pain, intolerance of light, and 
the other symptoms described in the last section, we find a puriform 
discharge, and some swelling of the eyelids. The eyelids, though 
frequently washed, quickly become glued together by the drying of 
the matter, so that, in making examinations, as well as in cleaning 
the eye, great mischief is frequently done by forcibly opening the 
lids, and thereby producing additional inflammation. After the 
disease is a little advanced, the eye, upon examination, will some- 
times be found in a state of chemosis, and we should make at least 
one daily inspection to ascertain the state of the cornea. If there 
be no opacity or dimness of the cornea, and no vascularity or ulcera- 
tion on its surface, the case may be regarded as doing well ; but 
should any of these circumstances be observed, the loss of vision 
may be dreaded. 

Treatment of simple catarrhal ophthalmia. — The same general 
plan of treatment as recommended in simple inflammation of the 
conjunctiva should be had recourse to. Attention must be paid to 
discover when the disease has passed into the chronic stage, that we 
may have recourse to remedies of an astringent nature; care should 
be taken to keep a small piece of linen twice folded constantly 
applied wet to the eyes; at all events, the eyes should be well soaked 
with some tepid fluid, before any attempt is made to separate the 
palpebral I shall hare to speak hereafter of the proper plan of 
treatment when ulceration of the cornea takes place; I shall now 

only farther mention, thai the inner membrane of the eyelids is fre- 
quently left, at the termination Of the disease, in a soft, swollen, 
ipOBgy condition. Should the ordinary astringents fail, the scissors 
of the Burgeon, or what, pel haps, answers fully better, the application 
Of lunar caustic, may be Used Once every third day, taking rare to 
evert the eye-lid completely, ami to bathe the part with a little milk 
the moment after the caustic has passed over its surface; this renders 
it innocent to other puts of the eye. In the acute stage, the warm 
bath and antimony will be found peculiarly serviceable, as well as 
repeated doses of Dover** powder. 

in bases where the introduction of syphilitic virus into the eye is 
inspected, it must be left to the discretion of the practitioner whether 
to use mercury 01 not Perhaps it ought not to be given in the first 
instance ; but in the case of syphilitic, gonorrhoBal, or any other acrid 
matter producing inflammation, the knowledge of the fact should 
lead us to watch the progress of the case more anxiouslv, and bo 
53 



630 INFLAMMATION OF THE CONJUNCTIVA. 

ready to apply the most potent remedies speedily, should they be 
necessary from the extent and intensity of the inflammation. An 
interesting case may be mentioned, which terminated very fortu- 
nately : — A young man came to the hospital with violent inflam- 
mation in one eye, attended with slight purulent discharge; he 
complained of excruciating pain both in the eye and head, and a 
large ulcer was discovered on the cornea. Upon examination, a 
purulent discharge was observed coming from the urethra, although 
he had previously denied the existence of gonorrhoea. 

Notwithstanding the advanced stage of the disease, I instantly 
resolved to open a vein, as he was stout and plethoric, and as his 
pulse was strong and hard. There was little probability of saving 
the eye, and it was fully expected that the contents of the eyeball 
would escape in the course of twenty-four hours; but it was neces- 
sary to mitigate his sufferings, which he described to be agonizing. 
The blood was allowed to flow till the approach of syhcope. Slight 
epileptic convulsions followed, which went off immediately upon his 
being laid down on the floor; he was now in an extreme state of 
weakness, and was threatened with a return of the convulsions upon 
making the least exertion, as well as when he was raised for the 
purpose of being placed in bed. When in this state, it was a matter 
of surprise to me, to find scarcely a trace of one vessel upon the eye, 
which had a few minutes before been exceedingly vascular, and the 
ulcer on the cornea already appeared as if it had received a death- 
blow. The blood was accurately weighed, and the quantity found 
to be fifty-six ounces. In a day or two a slough separated, andjhe 
ulceration was found to have extended throughout the whole depth 
of the cornea.; the only part which remained was its lining mem- 
brane, which was pushed out by the aqueous humour, forming an 
appearance like a hernia. From this time the healing process con- 
tinued; the cicatrix which afterwards formed, at first interfered with 
the sphere of vision, but the patient could see. all objects above him ; 
gradually, however, the cicatrix diminished in size, a very slight 
speck is left on the lower part of the cornea, and vision is now quite 
perfect. • 



PURULENT OPHTHALMIA OF INFANTS. 

The disease of which I have now to treat, is an inflammation of 
the tunica conjunctiva of the eye; occasionally attacking children 
soon after birth, and frequently, when unopposed by proper means, 
rapidly destroying the structure of the eye, by producing alteration 
of texture of the cornea, and sometimes, though rarely, by extending 
to, and injuring the deep-seated parts of the eye. It is now many 
years since this disease first attracted the notice of medical men, but 
we had no good description of it till Mr. Ware, a celebrated oph- 
thalmic writer and practitioner, published an account of it, and he 
was soon followed by several continental writers, particularly by 
Reilius and Schmidt in Germany. . 

The tunica conjunctiva ,and the reflection of it forming the lining 



INFLAMMATION OF THE CONJUNCTIVA. 631 

membrane of the eyelids, has been considered, and, I believe, very 
properly, as a mucous membrane. It is the principal seat of the 
disease, and undergoes a change, when inflamed, analogous to that 
of other membranes of the same class. 

Symptoms of purulent ophthalmia. — The date of the attack 
varies. I have several times seen children born with the disease, 
and have often detected it on the second day, and it may occur at 
any subsequent period ; but, generally speaking, it takes place be- 
fore the sixth week, usually during the course of the first fourteen 
days. It may attack one eye only, but it commonly happens that 
both eyes are simultaneously afTected. 

It is often difficult, if not impossible, to write a good description of 
the symptoms of a disease in infancy, but I shall here record nothing 
but what I have noted down at the bed-side.— A child affected with 
purulent ophthalmia, is observed to be very restless and fretful, par- 
ticularly when exposed to light, although it keeps the eyelids firmly 
closed; it never opens thein to look about, as infants usually do, 
who are readily attracted by the light of a candle or the blaze of a 
fire. At the onset of the disease, a slight redness is first observed 
on the conjunctiva lining the eyelids, especially about the inner 
canthus, attended with a secretion of whitish matter. There are 
generally observed also some heat of skin, and a foul tongue. The 
eyelids soon appear red and swollen, or the eyelashes are found 
matted together by a glutinous exudation. Whenever any of these 
appearances are observed, the eye should be minutely examined, 
alter it has been properly soaked with warm milk and water, so as 
to soften the matter which seals the lids together. On no account 
ought the examination to be proceeded in before this preparatory 
Btep is fully accomplished, as I have seen great mischief done by 
nurses and impatient medical men forcing open the eyelids, thereby 
occasioning great immediate suffering, and subsequently increasing 
the inflammation. 

I hope n» be excused by those medical men who largely indulge 
in the filthy habit of taking Bnnff, for urging upon them the necessity 
of taking care that the fingers employed in opening the eyelids are 
in, sud thai they keep their noses in such a situation, that none 
of the noxious herb may fill into the eyes of the poor little sufferers. 
\ | roceeds, a discharge of tears mixed with the secre- 

tion lakes place when the eyelids are separated, and the itching isso 
■ that the fingers of the child can scarcely be kept away from 
the • King of the eyelids soon follows; the discharge in- 

Bfl in quantity, becomes more puriformj and sometimes so acrid 
excoriate the cheeks. 

The inflammation, it 'it have not already affected that part of the 
conjunctiva which covers the eyeball, soon extends to it ; numerous 
blood-vea n oi a bright scarlet colour, sometimes giving the 

appearance <>\ chemosis; the quantity of matter is occasionally very 
great indeed, and when the eyelids are allowed to be glued together 
for some time, it collects, producing great distension, and when they 
are opened, a leaspoonful «»r two <>i puriform matter gushes out In 

'sum the cornea, perhaps on the first 



632 INFLAMMATION OF THE CONJUNCTIVA. 

examination, or that it is already destroyed. The external skin of 
the eyelids in some cases becomes affected, being red, swollen and 
of a livid colour, particularly when the infant struggles or cries. The 
inflammation, in some instances, extends to the lachrymal sac and 
duct and lining membrane of the nose, from which a similar puri- 
form fluid is discharged. 

As the complaint advances, portions of the cornea put on a dusky 
appearance, become elevated, and, in the course of perhaps twenty- 
four hours, a process of separation commences. The slough, when 
thrown off, leaves a ragged ulcer of an ash colour, the bottom of 
which is coated with a brownish matter. These sloughing ulcers 
vary in number, generally there is only one, sometimes there are 
several, and occasionally the whole cornea sloughs at once. As soon 
as one slough separates, another begins to form, which process goes 
on, if the disease be not arrested, until the ulcer penetrates into the 
anterior chamber of the eye, when the aqueous humour is discharged, 
and the iris pushed through the opening. The ulcer on the cornea 
may not be disposed to heal, or may enlarge, allowing more and more 
of the iris to protrude, which, in its turn, ulcerates; at last it happens, 
in some neglected cases, that the lens and vitreous humour are ex- 
pelled, and vision is for ever destroyed. In some rare instances, with 
or without opacity or ulceration of the cornea, the inflammation ex- 
tends to the deep-seated parts of the eye, and vision may be destroyed 
by internal disorganization. 

Such is a general outline of this disease in its most malignant form, 
when allowed to run its course, or when the inflammation is aggra- 
vated by improper treatment — a disease which, when early opposed 
by proper means, is seldom productive of any bad effects. When the 
inflammation is arrested at the period that the cornea first begins to 
slough, opacities or small specks are generally left; but when it ad- 
vances still further, and the iris is protruded, staphyloma is generally 
the consequence. 

It has been supposed, by some authors, that the acrid discharge 
produces the ulceration of the cornea— by others, that the cornea 
begins to ulcerate from within; but I believe the best informed prac- 
tical men are convinced that both opinions are erroneous, and that 
the disorganization of the cornea arises solely from the violence of 
the inflammation ; and it is highly important to keep this fact in view. 

Much irritation and discharge are sometimes kept up for a con- 
siderable period by a diseased state of the lining membrane of the 
eyelids, which, when examined, present a swollen, spongy, granular 
appearance, and more or less of a red colour. This state of parts 
frequently occasions relapses,till at length chronic inflammation steals 
slowly on some tissue of the eyeball itself, which ultimately impairs 
or destroys vision. 

Causes of purulent ophthalmia of infants. — These are stated to 
be various. The most common are cold and damp, exposure to too 
much light and heat, to which infants are very liable when nursed in 
the lap, and to smoke or acrid vapours; and I believe it is occasion- 
ally produced in consequence of mechanical injury inflicted on the 
conjunctiva by the child's own nails. Purulent ophthalmia is said, 



INFLAMMATION OF THE CONJUNCTIVA. 63S 

by some, to be produced by the direct application of acrid matter to 
the eyes of the infant during parturition. This is very probable, if the 
mother be affected with syphilitic chancres, or gonorrhceal discharge; 
but, on the other hand, I have known many women so diseased, 
whose children were not attacked by purulent ophthalmia. Others 
maintain, that it is invariably produced by the peculiar discharge 
called the whites: but experience completely disproves this assertion; 
for if it were the case, scarcely one new-born babe could, by possi- 
bility, escape, as a very large proportion of women are affected with 
whites during pregnancy, particularly in the latter months. 

Treatment of purulent ophthalmia of infants. — Regarding the 
disease, in severe cases, as one of intense inflammation, the treat- 
ment is easily understood. The only difficulties with which practi- 
tioners have to contend are, first, to determine whether or not the 
disease be too far advanced to admit of any hope of success; and 
secondly, whether or not the inflammation has yet become chronic. 
With respect to the former, it may be stated, that long standing and 
most unpromising cases occasionally do well under the active manage- 
ment which is here recommended. We must not allow ourselves to 
be guided by the number of days the disease has existed, but by the 
state of the eye itself after minute and careful examination, compar- 
ing that with the constitutional symptoms, together with the strength 
and peculiarities of the patient. With respect to the second difficulty, 
some experience is no doubt required. The appearances presented 
by chronic inflammation, ho wever, have been already fully described, 
and must he kept in recollection. 

It has been already stated, that both eyes are generally simulta- 
neously inflamed, but one eye is found to be more intensely affected 
than the other; young practitioners must be upon their guard not 
to fall into a common but very natural error of directing their sole 
'attention to that organ which is in the most dangerous condition, to 
the comparative neglect of the other, which, when subsequently ex- 
amined, is too often found to be irreparably lost. General bleeding, 
m early infancy, i^ altogether oul of the question^ therefore we must 
have recourse in leeching; and most infants stand the effects of the 
application o| iwo leechefl remarkably well, if the draining of blood 
he not allowed to go on too long. If' both eyes be affected* a leech 
may be put on each temple, within about half an inch of the exter- 
nal canthua <>l" the I -ys for when applied too near the part, the 
loose tisane of the eyelid becomes swollen, inflamed and ecchy- 
DBOSed) creating alarm and an impression in the minds of those most 
interested, that tin: abstraction of blood has done harm. This opin- 
ion may make them unwilling to repeat the application of the 
leeches, which should be done, perhaps, every four or six hours, 
according to the strength of the patient, nil the violence of the dis- 
ease is subdued. The bowels are t'> he acted upon by two or three 
smart purgatives, repeated at short intervals, such as one grain of 

calomel combined with two grains ofscammony; hut subsequently, 

milder means may he bail recourse to. It is of great consequence 
to keep tie: eyes clean, not became the matter, if allowed to lodge, 
would injure the cornea, but to prevent it from sealing the lids toge- 

5S« 



634 INFLAMMATION OF THE CONJUNCTIVA. 

ther. This is best effected by keeping the infant upon its back, 
while a small piece of wet linen rag is applied to each eye, and a 
little milk and water dropped occasionally upon the inner canthus. 
The necessary precautions already mentioned, before any attempt 
is made to separate the lids, must be carefully observed. 1 have 
seen much mischief done by the incautious and too frequent use of 
the sponge, as well as by injecting fluids between the eyelids, an 
operation which ought never to be confided to a nurse. 

With respect to the operation of scarifying the lining membrane 
of the eyelids, I formerly had doubts whether it did not occasion- 
ally do harm; but experience has taught me, that it is one of the 
most effectual parts of the treatment, not only in the chronic, but 
in the acute stage. The scarifications are to be made very slightly, 
as their edges sometimes suffer from subsequent irritation and in- 
flammation. To procure the full effects of scarifying, the eyelid 
should be carefully everted, the child steadily held, and a large 
quantity of blood allowed to flow before the part is returned ; to 
effect which the scarificator should have a very fine edge ; and in- 
stead of wiping the surface with a warm sponge, it should be done 
with a piece of dry soft linen. Scarifications are also occasionally 
of great use in the chronic stage, when the part is very vascular; 
and they are often serviceable after the membrane becomes soft, 
spongy and granular. 

The light should be excluded from the apartment. In bad or 
doubtful cases, the state of the cornea should be minutely examined 
twice a-day, and once when the case is going on well. The warm 
bath ought to be used morning and evening; the diet should be 
restricted at this early period of life to the breast milk. We judge of 
the effects of the remediesin reducing the disease, partly by the dimi- 
nution of the constitutional symptoms and quietness of the infant^ 
and partly by the diminution of the discharge, as well as by the child" 
opening the eyes ; but in order to ascertain this last point, it is neces- 
sary to watch its motions before light is admitted into the apartment, 
because the moment this takes place, the eyes will be closed, and 
the child will forcibly resist their being opened. 

An occasional opiate will be found useful in allaying pain and 
irritation, and producing sleep. One drop of the sedative solution 
of opium forms a good full dose. The state of chronic inflammation 
has been already frequently alluded to, but, perhaps, in the circum- 
stance now under consideration, it is a term not very happily chosen. 
After acute inflammation of the eye has subsided, the vessels are 
left in a gorged state; the swelling in the surrounding tissues gra- 
dually diminishes, leaving the vessels tortuous and loose, the blood 
contained in them being of a darker colour : the inflammation is 
destroyed, but the vascularity remains, and the remedies which sub- 
dued the previous action will, if continued, rather tend to increase 
than diminish it. At the same time, I have to urge the remark 
which I made in a former instance, and which applies with double 
force to the diseases of such a delicate organ as the eye, viz.: that 
practitioners are too meddlesome, and do not give sufficient credit to 
the restorative powers which a living organ possesses; or, perhaps, 



INFLAMMATION OF THE CONJUNCTIVA. 635 

from their own physiological and pathological dimness, ihey must 
always he doing something for appearance's sake. I have seen 
much mischief done by officiousness ; therefore, as soon as the in- 
flammation is either nearly or altogether subdued, I follow a pass- 
ive plan with respect to applications, and content myself with keep- 
ing the eye tolerably clean, and the eyelids unsealed, at the same 
time that the precautions with respect to light, diet and state of the 
bowels, are strictly attended to. In a day or two after convalescence 
has been established, an astringent, nay, even a Stimulating applica- 
tion, may be necessary and serviceable, should the vascularity still 
exist, or should the mucous membrane be in the fungous, granulated 
state already mentioned. Many use the application as a matter of 
routine practice, whether these conditions exist or not, so that they 
often irritate the eye and produce relapses. Should the fungous 
granular state resist the use of ordinary means, caustic must be ap- 
plied, or surgical aid obtained and the part clipped or cut off — at first 
recommended by Reid, who, by the date of his work published in 
1706, appears to deserve the merit of the originality of the plan, 
winch has been of late years again brought before the profession by 
Mr. Saunders, and claimed as a discovery by Sir William Adams. 

Immediately on the decline of the disease, some insist much upon 
the benefit to be expected from tonic medicines; but whatever may 
be said in their praise in old worn-out constitutions, their effects in 
early infancy are very questionable. In some cases, where consider- 
able debility prevails, particularly where there is a somewhat exsan- 
guined appearance, I find considerable benefit from the occasional 
exhibition of one, two or three drops of brandy mixed with a little 
milk from the nurse's breast. To many great and pompous practi- 
tioners, who depend upon mystery, this plan may appear vulgar and. 
unscientific — let such people give a few drops of " Iluxham's tinc- 
ture of hark." 

The experienced reader will have remarked, that the effect of blis- 
tering has u«>t hitherto been noticed in the treatment; but it was 
purposely avoided] to be made the subject of my concluding obser- 
vations. In the general remarks, I have already spoken of the 
advantage rived from the application of a blister to the 

temples, behind the ears, or |o the back of the neck, in inflammation 

of the eyes: the same benefit may be expected in purulent ophthal- 
mia ; but in young infants, the blistered surface is liable to slough, 
and death will bo frequently follow such an occurrence, that I enter- 
tain considerable repugnapce at applying a blister to a new-born 
child; and it is impossible I shall ever forget the fright experienced 
on the last occasion I applied one in purulent ophthalmia. The case 
w is severe ; the parents bad beard ot the good effects of blistering, 
and I was urged by them to apply one. My objections were honest- 
ly mentioned, but they still insisted; and a blister was accordingly 
appli-d, with the precaution, too, of placing a piece of fine gauze 

between it and the skint adeep slough took place, and the child 
made u narrow escape from death. 



636 INFLAMMATION OF THE CONJUNCTIVA. 



PUSTULAR OPHTHALMIA. 

This disease appears to be a chronic, or, perhaps, rather a subacute 
inflammation of the conjunctiva, speedily terminating in the forma- 
tion of pustules. At the commencement, these pustules have a red 
or yellowish appearance, slightly elevated, surrounded by a consider- 
able turgescence of vessels, varying very much in size, number and 
situation, and sometimes attended by considerable pain ; but at other 
times no inconvenience is complained of, either local or constitutional. 
It is a disease produced by exposure to cold. 

Treatment of pustular ophthalmia. — In general, this is a very 
manageable disorder, and is quickly cured, dropping into the eye a 
little vinum opii, or a solution of nitrate of silver twice a-day. But 
should the pustules be very painful, attended by headache and fe- 
brile symptoms, and more particularly, should they be situated upon 
the cornea, where they sometimes leave ulcerations, more active 
means should be employed. A number of leeches must be applied, 
perhaps a vein opened, a few strong purgatives exhibited, and re- 
course had to the other means which are employed in cases of severe 
inflammation of the eye. After the acute inflammation is subdued, 
which we are to judge of by the diminution of the symptoms, the 
vinum opii may be used. Should ulceration take place upon the 
cornea, it is to be treated in the usual manner. I have been assured 
by Dr. Robertson, that much greater advantage has been derived 
from the application of blisters behind the ears or to the nape of the 
neck than from any other means. 



CHAPTER III. 
INFLAMMATION OF THE EYEBALL. 



1. Inflammation of the Sclerotic Coat.— 2. Inflammation of the 
Iris. — 3. Amaurosis. 



INFLAMMATION OF THE SCLEROTIC COAT. 

Inflammation of the sclerotic coat is distinguished from that of 
the conjunctiva by the vessels being of a more pinky hue, by their 
lying deeper, and by their not being movable on making the con- 
junctiva slide upon the sclerotic, by pushing the former membrane 
from side to side with the finger, the eyelid being slightly interposed 
between the finger and the membrane. The pain complained of in 
this disease is a rheumatic kind, and more uneasiness is felt in the 
ditferent motions of the eyeball ; it is also, in many instances, vica- 
rious, with gouty and rheumatic affections of other parts of the body. 
In such instances, remedies which prove useful in rheumatism and 
gout are to be used, in addition to those required in simple inflam- 
mation. Of these I may mention that I have seen great advantage 
result from the exhibition of colchicum and Dover's powder. In 
almost every case of iritis the sclerotic is found to participate in the 
inflammation." 



INFLAMMATION of the iris. 

Inflammation of the iris received the denomination of in'/ is from 
Dr. Schmidt, of Vienna, and by that term it is now generally known. 
Tip- symptoms are of a very violent nature when the inflammation 
is BCUte, particularly after it has existed for twenty-four or thirty 
hours, when the patient's Bufferings are often agonizing ; severe pain 
over the eyebrow is rarely wanting; it commonly comes on in pa- 

• I have thought it unnecessary to treat of inflammation of the sclerotic coat at 
much length, becau •■ It I ■< dl es e which rarely takes place unless the Inflammation 
be con net it or rheumatism, oi have spread from other tisanes. Neither 

shall I treat "i inflammation "i the choroid coat, sill gh I believe ii sometimes 

oe.-ur^ uncomplicated. I most, therefore, refei my readen i"i more minute Inform- 
ation on these subjects, to any ni the onmerons wot Its upon the eye, Find pai licularly 

to ti Compendium of the i the Eluman Eye," by Mr. Watson, of 

Edinburgh. 



638 INFLAMMATION OF THE EYEBALL. 

roxysms. The constitutional symptoms are very similar to those 
which occur in other acute inflammations of the same organ, but 
there are local appearances which are highly characteristic. 

In iritis, vessels are seen running in straight lines towards the 
cornea beneath the conjunctiva, but they suddenly disappear before 
they reach the cornea, leaving a whitish zone round it. This ap- 
pearance is peculiar, and no doubt arises from the vessels passing at 
this part through the sclerotic to be ramified on the inflamed iris. 
As soon as the zone appears the iris loses its proper colour; in some 
rare cases it becomes distinctly red. Jannin relates a case in which 
the iris resembled a piece of raw flesh ; Beer" saw it of a blood-red 
colour, and Conradi observed it of the same colour after a wound of 
the eye. Dr. Robertson states, in a paper on iritis, in the Edinburgh 
Medical and Surgical Journal, that more than once he has seen spots 
of a blood-red colour upon its surface. When the iris changes its 
colour, it first commences at the pupillary margin, and the colour it 
assumes when inflamed is that which would be produced by a mix- 
ture of red blood with the natural pigment of the iris. The pupil 
becomes contracted and irregular, being slightly drawn upwards and 
inwards. It is also worthy of being mentioned, that the vessels, in 
iritis, as in inflammation of the sclerotic coat, present a peculiar pink 
colour. 

The retina sometimes becomes affected. This is indicated by 
greater sensibility to the impression of light, deep-seated pain darting 
through the head, and an appearance of sparks of fire and flashes of 
light before the eyes. If iritis be not speedily cured, it terminates 
by the effusion of small masses of lymph, sometimes even of blood, 
and more rarely by the effusion of puriform matter. The first-men- 
tioned terminations probably take place when the serous membrane 
covering the iris is principally affected ; the last, when the substance 
of the iris suffers a high degree of inflammation. The effusion of 
lymph sometimes produces adhesions between the margin of the 
iris and the capsule of the lens, by which its motions are complete- 
ly lost, the pupil subsequently remaining immovable under every 
change of light. When the effusion is considerable, it is seen hang- 
ing in tufts from the pupillary margin, or stretching in bands across 
the pupil, and sometimes exists in such quantity as to destroy vision. 
Occasionally this effused lymph becomes organized, and red vessels 
may actually be traced by the naked eye. Another termination of 
the disease is by the formation of an abscess in the substance of the 
iris itself. Its situation varies, but, for the most part, is found on or 
near the pupillary margin. This abscess may terminate in two 
ways — by bursting, as most frequently happens, and discharging its 
contents into the anterior chamber, forming the appearance which 
is called hypopion ; or, as the disease declines, by the absorption of 
the matter. In some rare instances, it has happened that ulceration 
has taken place after the discharge of the matter from the abscess. 

In this disease the iris is sometimes pushed forward towards the 
cornea, assuming somewhat of a conical shape; and occasionally it 
comes in close contact with the cornea, now and then adhering to it 
by the pupillary margin, and generally by a single point. It has 



INFLAMMATION OF THE EYEBALL. 639 

often been remarked that, when the iris of one eye is affected, the 
disease frequently attacks the other, and sometimes both eyes are 
affected simultaneously. 

Causes of iritis. — Cold is, no doubt, the most frequent cause of 
iritis; it may be also produced, as has already been slated, by the 
extension of inflammation from other tissues, as well as by external. 
injuries, and the application of too stimulating remedies for the cure 
of acute external inflammation. It is alleged by most authors, and is 
very generally believed, that iritis is most frequently excited by the 
action of mercury; and it is rather a curious circumstance that mer- 
cury is, nevertheless, exhibited for the cure of the disease which it is 
alleged to have excited. This erroneous impression seems to have 
originated in the fact that people, when taking mercury, have been 
attacked with iritis. If mercury were a cause of iritis, I ought to 
have been very familiar with the disease, when the use of mercury 
was more in fashion than it is in the present day; it ought then to 
have been a hundred times more frequent than at present; but this 
is not the case. There can be no doubt, however, that iritis is apt 
to occur when a person, under the influence of mercury or any other 
debilitating remedy, lias been exposed to cold. 

Treatment of iritis. — At the commencement of the attack, one 
determined bleeding will do more good in checking the diseased 
action than repeated small bleedings. The quantity of blood to be 
drawn must be determined by the peculiarity of the case, and by the 
circumstances already so fully mentioned. Subsequently, recourse 
is to be had to topical bleeding, repeated or not according to circum- 
stances, and blistering. After the violence of the inflammation has 
been reduced by one general bleeding, our chief dependence is to be 
placed on the use of mercury, so as to affect the system very rapidly. 
This is a most important improvement in the treatment of iritis, for 
which we stand indebted to Dr. Par re; but it seems to have been 
known to Holt and oilier German oculists, long before its introduction 
into this country. The plan which I generally follow is to give a grain 
of calomel every hour during the day, and five grams at bed-tune in 
a pill, willi a grain or two of opium: perhaps Dr. Robertson's plan 
is preferable — to rive tw<> mercurial pills every hour, combined with 
opium, if they affect the bowels with griping or purging. As soon 
as the system becomes affected with mercury, the patient experi- 
ences a very considerable abatement of the pain, as well as of the 
feeling of fulness and tension of the eye ; the sight becomes improved 
and clearer; the redness diminishes ; the iris assumes us natural 
colour; and the irregular and Contracted state of (he pupil, as well as 
the effused lymph, (if any exist,) begins to disappear. I can most 
conscientiously join those who state (hat Ihey have often Been cases 
of iritis in which it was to he regretted thai mercury had not been 

given, and that they never had occasion to regret having prescribed 
it. When (he " /n/tlrur^ijrnji/mliia" was in greater vogue than at 

. 1 knew several surgeons who were temporarily affected 
by it till they lost the eyes of the patients from iritic inflammation, 

which they had never done before when they used mercury. They 
bitterly regretted having forsaken a plan winch they had previously 



640 INFLAMMATION OF THE EYEBALL. 

found so generally successful, to adopt another from the false assur- 
ances of its invariable success. Dr. Robertson thinks that mercury 
can scarcely be praised too highly in this disease, which, when al- 
lowed to proceed, more especially after lymyh has been effused, too 
frequently ends in the loss of the finest sense we possess. When 
once the pupil has been obliterated by the effused lymph, and time 
has been allowed to glide on, it is next to impossible to restore sight 
by any remedies we possess, for it becomes so completely organized, 
that even mercury loses its influence over it. The only resource 
that remains for the patient is the formation of an artificial pupil, at 
all times a difficult operation, and in such cases exceedingly apt to be 
unsuccessful from the recurrence of inflammation of the iris. Indeed, 
no attempt should be made to form an artificial pupil as long as the 
slightest susceptibility to inflammation exists; perhaps it ought never 
to be performed till one or two years after the occurrence of the iri- 
tis. In some constitutions, Dr. Robertson assures me he has derived 
great benefit from the use of colchicum, particularly in gouty and 
rheumatic habits, in which iritis is by no means unfrequent; so great, 
indeed, has been his success with this remedy, that he generally tries 
its effects before having recourse to the mineral. It is only, how- 
ever, where the disease has not proceeded far that he has been thus 
successful with this medicine. When lymph has been effused, we 
have no resource but mercury. He has tried iodine in such cases, 
and he thinks with some benefit, but they are not sufficiently nume- 
rous and precise to allow him to give a decided opinion with regard 
to its utility. He would, however, recommend its employment, 
together with that of the colchicum, to those ivho can see nothing 
but poisonous qualities in mercury. 

The extract of belladonna is to be rubbed over the eyebrow and 
forehead, or on the temple or cheek, early in the disease ; or a strong 
solution of it may be inserted between the eyelids every second or 
third hour. If no effusion have taken place, the pupil will be regu- 
larly and considerably dilated in the course of a short time ; but if 
adhesions exist between the iritis and other parts, the dilatation will, 
of course, be only partial. It is often necessary, when lymph has 
been effused, to continue the belladonna for some length of time 
after other remedies have been discontinued, in order the better to 
secure the natural functions of the iris. When the inflammation is 
severe, scarcely any dilatation is occasioned by the belladonna: its 
use will, however, prevent the pupil becoming still more contracted; 
but as the inflammation subsides, the advantage resulting from its 
application becomes more apparent. Some say, that as soon as the 
dilatation of the pupil is produced, the pain and other symptoms dis- 
appear, from which they infer that belladonna is a powerful remedy 
in destroying the inflammation; but this is not the case ; the dilata- 
tion merely indicates the cessation or diminution of the inflamma- 
tion, towards which it does not contribute. The extract of hyoscya- 
raus seems to possess the same qualities as that, of belladonna; so 
that, should the one lose its powers, the other may be substituted. 



INFLAMMATION OF THE EYEBALL. 641 



AMAUROSIS. 

The term amaurosis, as at present used, is employed to denote a 
partial or total loss of vision affecting one or both eyes, arising from 
various causes which destroy the functions or structure of the optic 
nerves and retina. The symptoms of amaurosis are so very various, 
depending upon the cause of the affection, that it is impossible to 
give a good general description of the progress and termination of 
the disease in this work, from want of space. I shall therefore be 
obliged to deviate from the general plan, and commence the subject 
by describing the causes, as far as they are known, upon which 
amaurosis depends. 

Causes of amaurosis. — 1. Amaurosis may be produced by in- 
flammation of the retina, which is fortunately a rare disease, as the 
severity of the symptoms occasions great suffering to the patient, 
and is frequently followed by loss of vision. The inflammatory 
action may be acute or chronic, a primary or a secondary disease; 
generally it is a secondary disease, the inflammation spreading from 
the choroid coat. 2. It may be produced by congestion of the ves- 
sels of the retina. 3. JBy congestion of the vessels of the brain, as 
in apoplexy. 4. By destruction of those parts of the cerebral mass, 
upon the healthy state of which vision depends, blindness being well- 
known to be the consequence of many affections of the brain — as of 
inflammation with extensive effusion into the ventricles— inflamma- 
tion of the substance of the brain — effusions at the base of the brain 
— and tumours pressing on the parts on which vision depends; blows, 
also, on the supraorbital region, have been known to produce the 
disease. 5. Narcotics, arid the abuse of ardent spirits, are so well 
known as the causes of temporary loss of vision, that they need not 
be mentioned. 6. Amaurosis lias been known to be occasioned by 
gastro-intestinal irritation, produced by worms — by indigestible mat- 
ters — and by particular articles of food. During the time of Bona- 
parte's political influence on the continent, he prohibited the import- 
ation of our colonial produce, and we are told, by Professor Beer, 
that amaurosis became more frequent than it had been formerly, 
owing to the substitution of vegetable matter, called chicoree, for 
coffee. 7. Amaurosis is sometimes vicarious with cutaneous affec- 
tions, and with discharges of various kinds. 8. Some cases are on 
record, where it took place during pregnancy. 9. It is also said to 
occur during dentition, whether in consequence of determination of 
blood to the head, or of disordered stale of the stomach and bowels 
does not appear. 

Symptom* <>] 'amaurotfa — It will be seen, from the preceding 
Statement Of the various causes of amaurosis, that it is impossible 
to d«>v<)(<: a sufficient number of pages in ibis work to a minute 
description ofn disease, the symptoms of which must be so very va- 
rious, occurring under such different circumstances. I may mention, 
however, thai imperfect vision, pain in tin; eyeball ami in the bend, 
flashes of light and illuminated sparks, dark spots, or other optical 
54 



642 INFLAMMATION OF THE EYEBALL. 

illusions, appearing before the eye, accompanied with a preternatural 
state of the pupil, which is generally dilated and immovable, announce 
the existence of this disease. But this state of the pupil is not al- 
ways present, and when present does not, exclusively considered, 
justify the inference that the eye is amaurotic, such states being also 
produced by the condition of the iris itself and the ciliary nerves, 
independently of disease of the retina. An irregular, dilated, and 
commonly immovable pupil, together with the loss of its jet-black 
colour, and a tremulous motion of the diseased eye, are the more 
common appearances of amaurosis. Sometimes amaurosis comes 
on suddenly; at others gradually and partially, the patient recover- 
ing vision entirely, and losing it again and again, till at last it be- 
comes permanently destroyed. Squinting with the diseased eye takes 
place in amaurosis, but it is not in general permanent; it is only 
remarked for a short time, after a person looks at another object, it 
being some time before the muscles of the diseased eye are able to 
place it in the same direction as the other. 

Treatment of amaurosis. — The remedial agents must vary ac- 
cording to the cause of the disease. It is quite evident that, in the 
first three causes enumerated — viz. : inflammation of the retina, 
congestion of the vessels of the retina and congestion of the vessels 
of the brain — depletion by opening a vein, and applying leeches or 
cupping-glasses, more or less actively pursued, must be had recourse 
to; the chief circumstance of consequence is promptness. In the 
fourth case, viz.: disease of the cerebral parts on which vision de- 
pends, as concussion, inflammation and tumours, I have to remark 
that, in the two former states of the brain, the treatment necessary 
for the removal of such diseases must be had recourse to, but in the 
latter no treatment can have any effect. In the cases produced by 
narcotics and intoxicating liquors, the amaurosis is only temporary; 
if the patient recover from their effects, the sight, for the most part, 
is restored. In cases depending upon gastro-intestinal irritation, the 
offending cause must be removed, and the bowels subsequently at- 
tended to. Should the disease be connected with cutaneous affec- 
tions, and with discharges, bleeding may produce relief, but it will 
be only temporary: the chief dependence must be placed, either on 
restoring the cutaneous disease, or the discharge, or using means to 
enable the constitution to do without them, viz.: by the occasional 
application of leeches, but especially free purging, and a dry, un- 
stimulating diet. Occurring during pregnancy, it will, in all proba- 
bility, vanish, like many other unpleasant symptoms, after delivery; 
but a minute investigation should be made in case the amaurosis 
should depend upon some of the other causes, when suitable reme- 
dies are to be used. If the disease should ever take place during 
dentition, leeching and purging will be necessary; but lancing the 
gum will be found to be the most certain remedy. 

Nux vomica has been long known to possess considerable powers 
in paralysis, and since its active principle, strychnia, has been dis- 
covered, it has been found of more service in the same set of affec- 
tions. Strychnia has been lately tried in France, in amaurosis, by 
Lembert, and in some cases with marked benefit. It is evident, 



INFLAMMATION OF THE EYEBALL. 643 

however, that, as a cure is not to be looked for in paralysis of a limb 
if its structure be destroyed, or the brain and spinal marrow or 
principal nerves be diseased past recovery, so neither can we expect 
to cure amaurosis by strychnia, or any other remedy, if the structure 
of the eye be destroyed, or if any organic lesions exist in those parts 
of the brain which are known to be connected with vision. But I 
have no floubt strychnia will be found serviceable in amaurosis 
depending upon different functional derangements. It has been 
lately introduced into this country, and has been used in the Royal 
Infirmary of Edinburgh, by Dr. Shortt and Mr. Liston. The man- 
ner of employing it is to sprinkle a quarter of a grain daily upon a 
newly blistered surface on the temple, increasing the quantity gradu- 
ally till some manifest effect is produced. The blister requires to be 
renewed every third or fourth day; a little smarting is felt on the 
application of the strychnia, and it has produced erysipelatous in- 
flammation of the part. The constitutional symptoms occasioned 
by ihe strychnia are headache, agitation, and tremors of the whole 
body ; sometimes shooting pains in the eyes, and occasionally cramps 
and convulsions have followed. When any unpleasant symptom 
takes place, the dose is to be lessened or intermitted. It is stated 
that the best antidote is the application of the acetate of morphia to 
the blistered part, or the internal use of opium. The reputation of 
the remedy is likely to be very much injured by the indiscriminate 
and empirical use which may be made of it. 

The experiment has been tried by Dr. Shortt, and with complete 
success in three cases; but out of five cases treated by Mr. Guthrie, 
in the Westminster Ophthalmic Infirmary, in one instance only was 

evident and ooneidorabl© bonofit obeorvod. 

I have lately had occasion to try strychnia in a case of amaurosis 
in a young gentleman. The disease succeeded a severe blow on the 
left temple; considerable inflammation of the corresponding eye 
followed, and vision was destroyed. The organization of the alfected 
eye looked perfect when he fell under my care; the pupil contracted 
on the application of light; and he could always perceive the diifer- 
between night and day. Daily, for a week, a quarter of a gram; 
of strychnia was applied upon a recently blistered surface on the 
temple. No effects were produced except preventing strabismus. 

During four days, half a grain was used daily. One day half a grain 
was applied twice j a pricking sensation was felt in the hands and 
feet : on this occasion, dining sleep, he was observed to be affected 
with slighl Bpasmodic twitches and general starlings. For two days 
after this, half a grain was applied daily, and on the third day a 
whole grain was used without any benefit. 



CHAPTER IV. 
DISEASES OF THE EAR. 



In this chapter I shall treat, and that shortly, of Otitis and Otor- 
rhea. 



The symptoms of this affection may be considered under three 
heads, viz.: 1. Common earache; 2. Inflammation and suppuration 
external to the tympanum ; and, 3. Inflammation and suppuration 
of the internal ear, which are sometimes connected with caries of 
the petrous portion of the temporal bone, the disease spreading even 
into the brain. 

1. Earache. — This affection most frequently occurs during infancy 
and childhood; but adults are by no means exempt from it. It is a 
very painful, but not a dangerous disease, and is often ushered in 

with threatening symptoms, such as vinlpnt hpadnrhp, fits of scream- 
ing, flushed face, quick pulse, great restlessness, and sometimes de- 
lirium. 

2. Inflammation and suppuration external to the tympanum. 
— This disease is generally accompanied by more severe symptoms, 
and unless the inflammation be immediately checked, is of longer 
duration. It generally commences with rigors, followed by smart 
fever, flushing of the face, headache, severe paroxysms of pain dart- 
ing through the ear, and occasionally some degree of delirium; the 
ear is tender to the touch, and sometimes pressure cannot be borne. 
On examination, the inner membrane is found to be swollen, and of 
a red colour; and, in consequence of the swelling and inflammation, 
more or less deafness is produced, with an occasional hissing sound. 

3. Inflammation of the internal ear. — The symptoms, both local 
and constitutional, are generally, although certainly not always, more 
severe; and it is more important to subdue the inflammation in an 
early stage. If allowed to go on unmolested, the disease advances 
rapidly or slowly, according as the inflammatory action is acute or 
chronic, partial or extensive; the tympanum becomes ulcerated and de- 
stroyed together with the lining membrane of the different parts of the 
internal ear; the small bones are detached and discharged, and the 
hearing, on the side affected, becomes irreparably lost. When the bone 
is affected, the matter has a corresponding appearance and odour ; 
and as the disease advances in the bone, chronic inflammation of the 



DISEASES OF THE EAR. 645 

membrane of the brain succeeds, subsequently affecting the brain 
itself; so that, on dissection, the bone is found to be carious, with 
serous or purulent effusion, and extensive softening of the base of the 
brain. In some instances, the disease is very insidious in all its 
stages, attended with very little pain, and perhaps no discharge from 
the ear, till at last violent pain suddenly takes place, speedily followed 
by delirium and coma. In other instances, in which the attack is very 
acute, the painful symptoms cease, and coma gradually steals on ; so 
that the patient may be supposed to be recovering and enjoying 
sleep, when, in fact, he is in the very jaws of death. Sometimes 
spasmodic symptoms, and even convulsions, precede death. All 
modern writers on the brain notice such cases, and several interest- 
ing examples are recorded in Dr. Abercrombie's work on the brain, 
as well as in that of M. Itard, entitled "Traites des Maladies de 
l'Oreille." 

Causes. — All these varieties often take place in the course of ulce- 
rated sore throats, as only during the progress of the exanthematous 
diseases, where there is for the most part an affection of the throat. 
The three varieties may also be produced by cold, particularly when 
applied to the part. Thus I have seen some severe cases, from the 
ear having been exposed to a small current of air; but a more com- 
mon cause proceeds from the bad tricks which children have of 
putting pieces of paper, peas, &c, into the external ear. Another 
frequent cause of the first two varieties, and perhaps occasionally of 
the third, is the pernicious and disagreeable habit of picking the ears 
by means of various well-known contrivances. These complaints 
sometimes arise from a cutaneous inflammation, generally of an 
erysipelatous character, which extends into the ear. A collection of 
indurated wax in the ear, producing irritation and inflammation of 
the part, the larvae of insects, and even insects themselves, sometimes 
produce serious inconvenience and pain. 

Treatment. — The treatment of earache is well understood in the 
nursery ; medical men are therefore seldom consulted, unless in 
severe ami obstinate cases, to which the following observations will 
apply. If the paiu and other symptoms be not very severe, and 
should the inflammation of the inner membrane he slight, fomenta- 
tions assiduously applied during the day, and a soft light poultice 
during the night, together with the use of a small quantity of lauda- 
num, mingled with oil dropped into the ear, will generally suffice. 
When the symptoms are severe and the pain excruciating, I have 
seen the greatest benefit produced by opening a vein in the arm; 
but I have only thought it necessary to try this in cases where the 
symptoms were violent, and the disease of frequent recurrence, and 
in none of these instances has it ever returned. Besides fomenta- 
tions, the application of leeches is serviceable, to be repeated accord- 
ing to circumstances, and followed by a blister behind the ear if 
necessary. It is also found advantageous, before dropping in lauda- 
num and oil, to use an injection of milk and water, which will assist 

in softening and removing indurated wax, if any he collected. It is 

almost unnecessary to mention that the regimen should he mode- 
rately, if not entirely antiphlogistic ; and, in severe cases, a brisk action 

54" 



646 DISEASES OF THE EAR. 

is to be kept lip on the bowels: I have seen good effects from the 
use of antimony, particularly in cases complicated with rheumatism, 
or produced by exposure to cold. 

As soon as an abscess is observed it should be opened ; if not 
opened early, or if it be situated too deep, considerable additional 
suffering may be expected from the slowness with which the matter 
will form and escape, owing to its being situated in a hard and un- 
yielding structure. If allowed to take its own course, a troublsome 
fungous ulceration sometimes follows, and a copious discharge of 
matter, which occasionally continues for years. 



0T0RRHCEA. 

A discharge of offensive matter from the ear is at all times very 
unpleasant, more particularly so when it is habitual and in large 
quantity. Sometimes the discharge consists of an increased quan- 
tity of the natural secretion in a very fluid state ; at other times it is 
more or less mixed with pus. It may be the consequence of in- 
creased activity in the secreting vessels, but more frequently depends 
upon chronic inflammation of the lining membrane of the ear, and 
occasionally upon deep-seated inflammation and caries of the bones. 

In treating cases of this description, attention should be paid to the 
above-mentioned circumstances; and it should be also remembered, 
that after a discharge has existed for some time, it becomes, as it 
were, necessary to the constitution, and cannot be checked without 
creating some tumult in the system, which may terminate very un- 
pleasantly. Therefore, certain preparatory measures should be taken 
before the suppression of the discharge is attempted. Perhaps the 
best method of doing this is to apply repeated blisters behind the 
ear, to keep the bowels open by gentle laxative medicines, to use a 
light and a dry diet, avoiding slops, and a greater quantity of liquid 
than is sufficient to prevent thirst. After this system has been pur- 
sued for some time, then we may apply injections of an astringent 
nature ; and, if necessary, exhibit acetate of lead internally. In some 
instances, it may be well to keep a small blister open, or to apply 
tartar-emetic ointment to some other part of the body to produce an 
external irritation. Should headache take place, or a tendency to 
lethargy, a few leeches ought to be applied behind the ear, or cup- 
ping-glasses to the neck, followed by a blister, together with smart 
purgatives. In some instances, in which it might be unsafe to inter- 
fere with the discharge, the disagreeable fetor may be very much 
diminished, by injecting a solution of the chloruret of lime or soda, 
properly diluted. 



PART VII 



DISEASES OF THE SKIN. 



CHAPTER I. 
GENERAL REMARKS ON DISEASES OF THE SKIN. 



A knowledge of this class of diseases is so necessary in a prac- 
tical point of view, that I shall devote as large a space to their con- 
sideration as is consistent with the plan of this work. The study is 
important, from the frequency of their occurrence, from the little that 
is yet known respecting them, and from the connection, nay, I might 
have almost said the dependence, of cutaneous diseases upon the 
state of internal organs. 

These diseases have, for many years past, excited great attention; 
and the late Dr. VVillan has undoubtedly the credit of being the first 
to lead the way in the investigations which have taken place. On 
the continent, Alibert and Rayer have followed his footsteps ; but it 
is to be regretted that Alibert should have concealed, that the spring 
which first set his mind in motion on this subject, was the knowledge 
of what had been previously done by Willan ! 

Willan's great merit consists not only in drawing the attention of 
medical men to a subject which had been quite neglected, but in 
classifying the ditferent diseases, and in examining the writings of 
ancient medical authorities. It is incumbent, however, upon me 
to state, that the errors of his system are numerous, from carrying di- 
visions and subdivisions of cutaneous diseases too far, and increasing 
the Qfimber of names, thereby complicating the study without sim- 
plifying the practice. Practical physicians will, I feel persuaded, 
agree with me in this statement, and (heir opinion is of more value 
than that of scientific bookworms. Our sole object in classifying 
and investigating diseases, is to render the treatment more success- 
ful and certain, which a too minute division decidedly counteracts. 
The practitioners who, according to my observation, are notoriously 
tip- most unsuccessful in the treatment of cutaneous affections, are 
those who, instead of taking a comprehensive view of the history of 
the case, and attending to the state of the digestive and other organs, 
embarrass themselves by making minute distinctions, and by en- 
deavouring to force every disease into some of Willan's classes and 
ordere. 

Small-pOX, measles, and the other exanthemata, are included in 

almost all the popular works on cutaneous affections, and classed 

_■ with Other niSflasew With which they have no connection: as, 

lor example, With purpura. I have already treated of the cxanthe- 



650 GENERAL REMARKS ON 

mata, in the first volume, as fevers attended with eruptions — but 
my pathological opinions respecting these and simple cutaneous dis- 
eases, are in some respects very similar. 

In almost every instance of cutaneous affection which has fallen 
under my observation, whether attended by fever or not, I find 
ample evidence in the history of the case, of functional derangement 
of some internal viscus. In some, the stomach and bowels are at 
fault, as in urticaria, erythema fugax, many cases of lepra, &c.; while 
others are evidently connected with disease of the liver, mucous 
membrane of the lungs, &c. Erysipelatous inflammation is always 
the consequence of some internal disease, either functional or struc- 
tural, sometimes of the stomach and bowels, at others of the lungs, 
and occasionally of the brain. This will be shown when treating 
more particularly of erysipelas, which I have placed in this part of 
the work, and not among the exanthemata, because it cannot be 
considered a specific disease, having, like small-pox and measles, a 
definite course, progress, and termination. 

The principles which shall now be explained respecting cutaneous 
affections, are those which experience and observation have, from an 
early period of life, forced upon me, and which I have taught ever 
since I began to lecture, in the year 1823.* 

Practitioners pay little attention, in general, to the seat of the 
cutaneous disease ; and they have either very erroneous notions, or 
never think at all, of the nature of the affection. It may be briefly 
mentioned, in this place, that its nature is generally inflammatory; 
but that its seat is various, sometimes affecting the superficial vessels 
of the cutis which secrete the cuticle, as in recent cases of some of 
the squamous diseases; at others, the sebaceous follicles are the seat 
of the inflammation, it being frequently produced by the mechanical 
irritation of the sebaceous matter which collects in too large a quan- 
tity, so as to over-distend the follicle and irritate its vessels — as in 
acne, papulae, &c; whereas, in a third class of cutaneous affections, 
as erysipelas, small-pox, &c. the diseased action is situated in the 
substance of the cutis vera itself, the inflammation and suppuration 
extending to the subcutaneous cellular membrane, and in some in- 
stances even deeper still, affecting the muscles and other tissues, as 
in bad cases of erysipelas and carbuncle. I shall avoid speaking of 
the rete mucosum, because its existence, even in the negro, has been 
denied by good anatomists; as well as of a minute glandular dis- 
tribution, which some think they have seen by the help of the micro- 
scope between the cutis and rete mucosum. Microscopic obser- 
vations, like those performed by Mr. Chevalier, who describes the 
existence of these glands, are always liable to fallacy ; and it is well 
to remind those who have much faith in them, of the dilemma in 
which the late Dr. Monro (usually called secundus) was placed, by 
an optical delusion, in the course of a very extensive set of experi- 
ments which he performed. He observed that all animal fibres 
were serpentine ; he next proceeded with vegetable substances, and 

* It gives me great pleasure to notice the work on the Diseases of the Skin, by 
Mr. Plumbe, of London, and to recommend it to my readers as the best pathological 
and practical treatise on this class of diseases which is to be found in any language. 



THE DISEASES OF THE SKIN. 651 

he also found that their fibres were serpentine. Astonished at these 
observations, he next proceeded to examine mineral substances, and 
he was astounded by observing, that whatever substance he ex- 
amined, it was composed of serpentine fibres. He either wrote, or 
was engaged in writing a paper upon the subject, when he discov- 
ered, through a scientific friend, that the serpentine fibres were all 
produced by a slight defect in the glass of the microscope, which 
saved him further trouble at the time, as well as subsequent embar- 
rassment and chagrin. It is to be feared that considerable errors 
have crept into medicine, from the incorrect impressions conveyed 
by microscopic apparatus. 

Some writers have described papillae over the whole surface of 
the body, situated in the true skin ; but I am inclined to agree with 
Mr. Plumbe, who states that he has never been able to discover any 
vestige of them ; and if they do not exist, the diseases ascribed to 
this tissue should be erased from medical writings. Mr. Plumbe has 
used a very strong argument against the existence of the diseases 
which have been ascribed to the papillae of the skin : "Every genus 
of this order (papillae) makes its appearance on all parts of the body, 
at times, except where papillae are really and easily found." — (P. 7.) 

The skin performs several important functions: — 1. The formation 
and repair of the cuticle, which is insensible, like the nails, and forms 
an outer covering to the whole surface of the body. 2. The skin 
performs the office of separating a large quantity of a limpid fluid 
from the blood, which escapes from the body by what is denomin- 
ated insensible perspiration ; and the proper performance of this 
duty must have a powerful influence upon the action of every other 
organ in the body. 3. It would appear that we are able to introduce 
many substances into the body by the process of absorption from the 
skin ; so much so, that even minute quantities of strychnia, applied 
to a blistered surface, have frequently produced violent constitutional 
effects. 

In this work I shall treat of cutaneous affect ions in the following 
order, without splitting the orders into so many different genera and 
species, as is usually done. 

i. Erysipelas, or Rose. 
'j. Papular Diseases. 

:i. Pustular do. 

4. Squamous do. 

5. Vesicular do. 

6. Purpura. 



CHAPTER II 
ERYSIPELAS 



Erysipelas appears to have been noticed by the earliest writers 
on medicine, who frequently, however, confounded it with other 
diseases, under the general term of "ignis sacer." 

This disease has been divided into several varieties, viz.: idiopathic 
and symptomatic — erythematic — phlegmonous— erratic — bilious — 
local — malignant and putrid; and some of these have been again 
subdivided. 

All unnecessary divisions of diseases, as I have already observed, 
are useless in theory and injurious in practice. Mankind differ as 
much in constitution as they do in expression of countenance ; and 
it is well known that peculiarity of constitution produces shades of 
difference in symptoms and appearances, which defy the ingenuity 
of the ablest nosologists; but they, nevertheless, have exerted them- 
selves in a wonderful manner to accomplish the task, retarding instead 
of advancing the study of true pathology. If all the time and talent 
that have been misused in devising nosological arrangements had 
been employed in discovering the nature and seats of diseases, our 
knowledge of pathology and of remedial agents would, in all proba- 
bility, have been much further advanced than it is at present. 

I shall treat of all forms of the disease under the simple term of 
erysipelas, while I shall take care to notice the peculiar, as well as 
the occasional symptoms, appearances and terminations which may 
seem to indicate corresponding alterations in the treatment. I am 
induced to follow this plan here, because it has met with the appro- 
bation of practical men of considerable standing in the profession, 
who have done me the honour to attend my lectures. 

Phenomena of erysipelas. — This disease takes place in people of 
all ages; — I have seen it in new-born infants, as well as in extreme 
old age. It more particularly occurs, however, in certain constitu- 
tions, viz.: in those who are liable to affections of the skin, to gout, 
and who are subject to disorder of the stomach and bowels. It is a 
disease met with in practice in every degree of severity, appearing 
under the form of the slightest erythematic blush, confined to one 
spot, or under that of deep and intense inflammation of the skin, 
extending over the whole body. The inflammation may be severe, 
affecting not only the skin and subcutaneous cellular tissue, but also 
involving the muscles, and terminating in extensive suppuration, 
ulceration and mortification. In some cases the disease spreads 



ERYSIPELAS. 653 

from the skin to deep-seated parts, while in others the inflammation 
appears to extend from within outwards, sometimes from the perios- 
teum, when it is primarily inflamed, but more frequently from the 
tendinous aponeuroses forming the strong fasciae which bind down 
the muscles. In such circumstances, the general phenomena of the 
disease and the local appearances differ considerably from those of 
simple erysipelatous inflammation. When the periosteum is prima- 
rily affected, severe gnawing pain, sleepless nights, &c, will be com- 
plained of for months, perhaps for years, before the skin partakes of 
the inflammation. When the fascias of muscles become inflamed, 
whether from a puncture or from the application of cold, deep-seated. 
pain, tumefaction, tenderness to the touch, and severe constitutional 
symptoms, precede the redness of the skin. In contradistinction to 
erysipelas, these cases have been named, by Dupuytren and others, 
erysipeloid diseases, and appertain more to surgery than physic. 

The first local symptoms of erysipelatous inflammation are a 
tingling or pricking pain, with some degree of heat, swelling, tension 
and redness of the part. Soon a pungent, burning pain is experienced, 
aggravated by motion or pressure; the swelling increases rapidly; 
the surface presents a shining appearance ; on pressure the redness 
disappears tor a moment, but immediately returns; and, as the dis- 
ease advances, the part assumes a purple colour. 

The constitutional disturbance manifests itself in the shape of 
febrile symptoms and general functional disorder, varying according 
to a number of circumstances preceding the attack of erysipelas — 
such as the extent and severity of the disease, as well as its duration 
and situation. If the disease have appeared after a long and debili- 
tating illness, the symptoms will be different from those produced in 
a person who had been previously in good health. If the inflam- 
mation be superficial, the symptoms will be comparatively slight; if 
it be situated on the head and face, delirium and even coma may 
occur, which, in all probability, would not have happened if the 
disease had attacked an extremity, and were limited to the same 
extent of surface. 

The external characters of the disease vary much according to situa- 
tion, severity and duration ;— affecting the head and face, the features 
swell much, as in small-pox; the conjunctiva of the eye partakes of 
the inflammation, as erell as the membrane lining the nose, mouth 
and ears; vesication takes place, even in slight cases, or the parts 
become exceedingly hard, more particularly the cars; and if the 
inflammation he superficial, desquamation of the cuticle, after dimi- 
nution of the redness and pain, mark's the decline of the disease. In 
cases where the inflammation has been more intense and decper- 
ssatod, donghiness or boggineas is left, which renders it probable that 

Battel is effosed. <hi some occasions, distinct fluctuation leaves no 

doobt of tic existence of matter, winch may be either circurascribedj 

as in phlegmonous erysipelas, or diffused] as in the diffuse inflamma- 
tion of the cellular tissue that occurs in patients who are of a bad 
habit of body, and winch arises sometimes from a prick in dissection. 

The Circumstances preceding an attack are also very various; ery- 
sipelas frequently comes on at the termination of fevers of long dura- 
55 



654 ERYSIPELAS. 

tion, as well as of inflammations of different organs, more particularly 
of the brain, lungs, and peritoneum ; it also takes place in individuals 
who have laboured for years under different chronic diseases, medical 
or surgical. Those who have long indulged in the abuse of strong 
potations, as well as gourmands, are also liable to it. At other times 
it appears to be the immediate effect of cold operating on the general 
system, or of some indigestible matter in the stomach and bowels. 
In whatever circumstances erysipelas may take place, the attack is 
generally preceded by rigors or chilliness, alternating with flushes of 
heat, oppression at the prsecordia, difficulty of breathing, cough, ex- 
pectoration, pain in the back and loins, general uneasiness, delirium, 
a sense of weight in the head, headache, lethargy, and sometimes a 
state bordering upon coma, with high or low toned febrile action. 
These phenomena may exist with more or less severity for one day, 
or for twenty days, before the inflammation appears in the skin ; there 
are no regular periods or stages, as in measles, scarlatina, and small- 
pox. Erysipelatous inflammation sometimes appears on a part for a 
few hours, and suddenly vanishes, showing itself perhaps in another 
situation; or if it do not show itself again on the surface, the consti- 
tutional symptoms become aggravated, coma or dyspnoea frequently 
follows, and sometimes even death itself. 

Causes of erysipelas. — From the prevalence of erysipelas in par- 
ticular years, a belief is pretty generally entertained of its being con- 
tagious, which has been much strengthened by the additional fact of 
the occurrence of a considerable number of cases at one time in par- 
ticular hospitals. There is much stronger ground for believing that 
erysipelas is produced by epidemical influence. But the occurrence 
of the disease can, in the majority of cases, be much better accounted 
for by sudden changes of atmospheric temperature, along with con- 
siderable moisture, together with the state of the bowels, and indul- 
gence in particular articles of food. 

It is proper to state, that I deny altogether the idiopathic nature of 
erysipelas, and that I believe it to be an occasional symptom of dif- 
ferent diseases, which diseases may frequently occur, under atmos- 
pherical, epidemical, and contagious influences. 

In a great majority of instances, if the particulars of the cases be 
inquired into, it will be found that no communication, direct or indi- 
rect, had taken place with others labouring under erysipelas. Some- 
times it attacks nurses and others who have had an anxious attend- 
ance upon the sick, labouring under various diseases, as peritonitis, 
pneumonia, different kinds of fevers, fractured limbs, and injuries of 
the head. Some may have been attacked, no doubt, with erysipelas, 
when attending patients labouring under that disease. But such an 
event does not take place more frequently than during an attendance 
on patients affected with other diseases. I have seen a great number 
of cases of erysipelas, and have been greatly interested, from the 
earliest period of my professional life, in the investigation of its nature 
and seat; but have never met with a nurse or an attendant who was 
attacked with erysipelas when attending a patient labouring under 
that disease, although the confined, crowded, and extremely filthy 
state of the apartments, on very many occasions, seemed but too well 



ERYSIPELAS. 655 

calculated to contaminate the atmosphere, and thereby to promote 
the generation and communication of contagion. If erysipelas were 
as contagious as is represented, we ought certainly to see erysipelas 
producing erysipelas in the same determinate manner that small-pox 
and measles are known to produce these complaints; but I have 
never observed such a phenomenon. 

That erysipelas sometimes appears as an epidemic, cannot be de- 
nied, and on many occasions it is said to spread by contagion in hos- 
pitals ; but if it were an idiopathic disease, and contagious, it ought 
to spare none, or at least few who have an ulcer, or any abrasion of 
the skin. It ought to spread more or less slowly from one to another, 
so as at last to affect almost every one who approached within the 
sphere of the contagion. We find, however, that it only attacks indi- 
viduals here and there, frequently at a distance from each other, who 
have been in separate wards, and who have never come once in con- 
tact. This is very different from what occurs in small-pox, measles, 
and a few other diseases which are known to be contagious, and which 
are always marked by symptoms peculiar to themselves. In these 
there is an eruptive fever, which continues for a certain number of 
days before the eruption appears. This goes through a regular course 
of advancement and recession, and all the other phenomena only vary 
in intensity. Each disease is recognized under every circumstance 
of age, sex, and constitution. Neither small-pox nor measles can be 
generated by any of what are called the common causes of diseases 
not contagious, such as exposure to cold, damp and fatigue, affections 
of the mind, &c. 

Erysipelas sometimes does not appear in the course of fevers, in- 
flammations, and other morbid conditions of the system, till perhaps 
the end of the third or fourth week; at other times it occurs on the 
second or third day, and at all intervening periods. This is certainly 
very unlike the acute eruptive diseases which are known to be con- 
tagious; besides, erysipelas has no regular and determinate course 
as the others, which attack the same individual only once in a life- 
lime, while erysipelas may affect a person twenty times. Let me 
ask if any one has succeeded in producing erysipelas in a healthy 
on by introducing matter taken from an erysipelatous BUrface? 
This has been Stated, but I believe it to be a mere assertion : but 
even if this could be answered in the affirmative, it is no proof of 
the specific and contagious nature of erysipelas, because (he same 
affection has followed scratches received during dissection. It has 
followed the application of leeches and blisters, as well as injuries 
produced by minute splinters of wood, and punctures made by per- 
fectly clean sewing needles. In no point of view, then, fan erysipelas 
h>- mid i.) in- ;i specific disease, or to resemble other diseases which 
are known to he contagions. 

When erysipelatous epidemics have prevailed, I have always 
remarked that they have occurred either under sudden vicissitudes of 
weather, attended by considerable moisture, or during tin- autumn 
after a hut summer, when there was a great abundance of fruit in 
tho first circumstance, fevers, and acute ami subacute inflamma- 
tions, also prevail, particularly bronchitis. 



656 ERYSIPELAS. 

of the stomach and bowels suffer; irritation of their mucous mem- 
brane ensues; fevers and diarrhoeas also prevail; and the erysipelas, 
in both cases, although a frequent occurrence, is a mere symptom. 

The reason why erysipelas should be occasionally very prevalent 
in hospitals, and be attended with greater fatality than in private 
practice, can be easily explained. In this country, from the pride 
of being independent, it is only the most destitute of the poor — 
servants at a distance from their friends — or country people, who 
desire a consultation of doctors — who can be prevailed upon to go 
into an hospital. In hospitals, patients are generally too much 
crowded together; there is great irregularity of temperature in the 
wards; and sufficient attention is not paid, except at the hour of 
visit, to ventilation. 

These circumstances, and many others which could be adduced, 
enable us to account in a more satisfactory manner for the prevalence 
of erysipelas in hospitals, than by supposing, as too many have done, 
that the disease lies in ambush, embedded in the lime, mortar, and 
wood-work of the wards, watching favourable opportunities to seize 
on flesh and blood ! 

Appearances on dissection in erysipelas. — The part which had 
been the seat of the inflammation, will be found after death to have 
lost much, if not the whole of its redness, but not its swelling. Upon 
making an incision, a bloody serum will be found infiltrated into the 
cellular substance. The skin will be often seen thick and hard, in 
the same state as it is observed to be when a person has died twen- 
ty-four hours after a blister had fully risen; or, if suppuration have 
taken place, pus will be found infiltrated instead of serum, in some 
places distributed generally through the cellular tissue; in others, 
circumscribed little abscesses exist. In the most severe degree of 
phlegmonous erysipelas, the parts will be very tender, easily torn, 
and a large collection of fetid pus will be found, with more or less 
of the cellular tissue detached, and perhaps mortified, the disease 
even extending into the muscles. In subcutaneous cellular inflam- 
mation, more extensive destruction will be discovered; small ab- 
scesses will be found, but pus and a dark-coloured ichor will be seen 
generally and deeply diffused among the muscles, biood-vessels, &c; 
partial mortification and sloughing will have taken place here and 
there ; and, in some dissections, the muscles will be seen tender, and 
altered in appearance, resembling, in many cases, the last stage of 
putrefaction. I have seen the blood-vessels also extensively diseased 
in their inner coats, and the lymphatics as well as veins containing a 
puriform fluid. 

Besides the above appearances, traces of extensive disease in the 
membranes and substance of the brain, pleura, pericardium, and 
peritoneum have been seen. But of all the tissues in the body, the 
mucous membranes are most frequently found in a state of inflam- 
mation, and in many instances the fatal termination has been dis- 
tinctly traced to bronchitic inflammation. 

Some years ago, I was requested to visit an infant three days old 
who had shown symptoms of great suffering from the moment of its 
birth, which was attributed to colicky pains in the abdomen. On 



ERYSIPELAS. 657 

examining the abdomen, the commencement of erysipelatous inflam- 
mation was discovered, which, by the following day, had extended 
nearly over the whole trunk and thighs. Soon afterwards it began 
to sink, and died in about forty-eight hours after the first appearance 
of the external inflammation. On dissection, the most extensive 
ravages of disease were discovered in the abdomen, the effects of 
peritoneal inflammation — viz., considerable exudation, and the ag- 
glutination of the intestines to each other. 

My friend and pupil Dr. Yates, when attending my dispensary, 
was requested to see a child one month old, on a Saturday evening. 
He found the abdomen tumefied and tense ; there was an erysipe- 
latous spot about the size of a half-crown on the inner part of the 
right thigh near the groin; the child appeared to him to be danger- 
ously ill, but did not seem to be in much pain. Dr. Yates was 
informed that it had been taken ill on the preceding Thursday 
morning, after having passed a bad night; that the bowels were 
confined ; and that she cried violently at times, and gave evidence of 
abdominal suffering. By the following afternoon, the erysipelatous 
inflammation had extended over the whole abdomen, the child was 
in a moribund state and died on the following morning. 

Dissection. — The abdomen was considerably distended. The sur- 
face of the abdomen and thighs showed the remains of the erysipe- 
latous inflammation, and there were, besides, much tumefaction and 
discoloration of the integuments at the lower part of the chest. On 
opening the abdomen, the intestines, which were moderately dis- 
tended with flatus, appeared very vascular, as well as that part of 
the peritoneum which lines the cavity. Flakes of coagulable lymph 
of a yellow colour were spread over the intestines, and interposed 
between their convolutions, in some places forming slight adhesions. 
On displacing the intestines, a large quantity of this matter mixed 
with serum was found, a layer of yellow-coloured lymph covered 
the whole of the anterior and inferior surface of the left lobe of the 
liver, which adhered not only to the parietes of the abdomen, but 
was also glued to the stomach. The liver, when cut into, presented 
a very dark appearance, and the gall-bladder was nearly empty. 
The omentum was also covered Willi the above mentioned exuda- 
tion. The stomach distended With air, was found to adhere to the 
diaphragm as well as to the liver. The colon was much contracted, 
and on being slu open, its mucous membrane was found very vascu- 
lar, much elevated here and there, and coated with a dark, thick 
mucus. 

The viscera of the pelvis were found slightly matted together by 
recent deposition* of lymph. The ovaria were larger and softer 
than natural, and, with the uterus, were covered with coagulable 

lymph ; the left broad ligament was attached to the peritoneum at 

the brim of the pelvis, l>y an interposed mass of lymph. 

In the thorax, the pleura costahs was very vascular 00 both sides, 

and slight recent adhesions were observed with the pleura pulmo- 

nalis, by means Of large masses of lymph precisely similar to those 
met with in the abdomen and pelvis. 

The following case by Dr. Gartshore is extracted from the 2d 
55* 



658 ERYSIPELAS. 

volume of the Medical Communications. "The child of War- 
wick, in June 1773, was observed to be uneasy and hot, to vomit a 
yellow fluid frequently, and to have fewer stools than is usual for a 
child of that age. A gentle emetic was first given, after which 
manna was copiously poured down, and glysters frequently exhi- 
bited, notwithstanding which, his bowels were difficultly and scantily 
evacuated. Two days after the abdomen was observed to be swelled, 
tense, painful to the touch, and had an inflamed appearance, which 
extended to the scrotum. Gentle aperients, glysters, fomentations, 
and the semicupium often repeated, were of no avail. He died on 
the twelfth day from his birth, and the fifth from the attack. 

Dissection. — On opening the abdomen, we found the appearances 
very similar to what we had often observed in the true puerperal 
fever — viz., a purulent exudation covering the surface of the peri- 
toneum, and an adhesion of many of the viscera to this membrane 
and to one another from the diaphragm downward, with some ex- 
travasated fluid in the abdominal cavity. On laying open the 
scrotum, that also was swelled and inflamed, and we found purulent 
matter upon the surface of the epididymis and testis on each side; the 
testes themselves appearing inflamed. But though the chylopoietic 
and spermatic organs seemed to have undergone superficial inflam- 
mation, there was no appearance of any tendency to mortification. 

Underwood, when noticing the appearances on dissection in the 
bodies of several children who had died of erysipelas, states that 
"the contents of the belly have frequently been found glued to- 
gether, and their surface covered with inflammatory exudation, ex- 
actly similar to that found in women who have died of puerperal 
fever. In males, the tunicae vaginales have been sometimes filled 
with matter, which has evidently made its way from the cavity of 
the abdomen, and accounts for the appearances of the organs just now 
described ; in females the labia pudendi are affected in like manner, 
the pus having forced a passage through the abdominal rings." 
(Diseases of Children, vol. I. p. 36.) 

Some years ago, I was asked to see a father and son labouring 
under erysipelas of the head and face, as pure examples of idiopathic 
erysipelas. In both cases I was able to satisfy the gentleman who 
had been previously attending, that there was a general affection of 
the mucous membranes — that of the lungs in one, announced by the 
dyspnoea, cough and wheezing — and that of the stomach and bowels 
in the other, announced by thirst, very red tongue, tenderness and 
tumefaction of the abdomen. Both cases presented most unpromis- 
ing appearances; proper remedies were applied; stimulants with- 
drawn : one recovered, but suffered during several years from the 
effects of chronic inflammation of the mucous membrane of the air- 
passages, and alimentary canal. On opening the body of the fatal 
case, traces of inflammation of the membranes of the brain were 
discovered, viz., vascularity and effusion ; and, on slicing the brain, it 
was found to contain a larger quantity of blood than usual. The 
pericardium was attached to the heart at every point. The mucous 
membrane of the trachea and bronchia was found dark-coloured 



ERYSIPELAS. 659 

from vascularity, and the tubes were filled with tough exudation of 
a reddish colour. 

The mucous membrane of the stomach was red, vascular, and 
soft, easily separated, and covered with a thick tenacious exudation ; 
this was also the condition of the mucous membrane of the intestines, 
particularly of the ileum, where the vascularity was much greater 
than in the stomach, and appearances were discovered indicating the 
commencement of ulceration. 

In the year 1823, I was requested to see a woman with erysipe- 
las of the abdomen, which had commenced about a fortnight after 
abortion. The whole surface of the belly was affected, the inflam- 
mation was of a deep purple colour, with sloughing at the umbilicus. 
Although this woman possessed considerable property, she was liv- 
ing in a state of abject misery, neglected by a brutal, drunken hus- 
band, and had been long suffering in mind, as well as in body. A 
very imperfect account could be obtained, either of her previous or 
present symptoms. On the following day some of the mysteries of 
her case were removed by the separation of a slough at the umbili- 
cus, and the discharge of a large quantity of urine. The woman 
sunk under her sufferings; and on dissection, the peritoneal surface 
of the fundus of the bladder was found strongly attached to the peri- 
toneal lining of the abdomen corresponding to the umbilicus; the 
bladder appeared to have been enormously distended and neglected, 
till at last the urine found an exit by this process of nature. This 
valuable preparation is in my museum. 

The following abbreviated case of erysipelas is extracted from the 
pathological work of Tacheron. — A man was seized on 1st Febru- 
ary, 180S, with anorexy, nausea, headache, severe pain of neck, and 
difficult deglutition. These symptoms gradually increased for some 
days, the face becoming swollen, inflamed and painful, with severe 
diarrhoea. He had cough and expectoration, which afterwards 
became bloody, and the patient died on the 19th. The following 
appearances were found on dissection: "In the head there was 
effusion of serum in considerable quantity (Siss.) in the ventricles, 
between the membranes on the surface of the hemispheres, and also 
at the base of the brain. In the thorax several old adhesions 
were found between the surfaces of the pleura on both sides. The 
middle lobe of the right lung was reddish, hard, and did not crepi- 
tate; in consistence it resembled liver, and adhered to the portion 
of the mediastinum next the heart On cutting into this lobe, a 
thick, grayish, puriform fluid oozed out; the rest of the lungs being 
healthy. The pericardium adhered in every part to the heart, but 
particularly on its right side, where it could not be separated with- 
out tearing its substance. The heart was not much larger than 

natural ; there was ;i well marked ossification of one of the mitral 
valves, which appeared almost entirely detached. At the base of 
the aortic valves, there were- also observed points of ossification, and 
carlilagini/.alioii. In the abdomen the intestines were found dis- 
tended with gas; but, as well as the Stomach, were- in other respects 
healthy. The- liver was larger than natural, and had contracted 
preternatural adhesions with the diaphragm ; the convex surface of 



660 ERYSIPELAS. 

its left lobe was covered with lardaceous substance, which entered 
the substance of this viscus to the depth of two or three lines. The 
gall-bladder contained polyhedrous concretions of the size of onion 
seeds, and of a dark-green colour ; the cystic and choledic ducts were 
also filled with these substances. The spleen was three times its 
ordinary size, and so tender and soft, that the slightest pressure re- 
duced it into a pulp. The kidneys were more vascular than natu- 
ral." 

The two following dissections of erysipelatous subjects, are extract- 
ed from Dr. Hastings' work on the lungs: — 

"Dissection of case 5th, (page 228.) — The mucous membrane lin- 
ing the bronchia and air-cells, was found very much inflamed. The 
tubes were filled with frothy serum, which in some places was mixed 
with a substance very like pus. There were several small tubercles 
in the structure of the lungs, but none of them appeared inflamed. 
There were elongated adhesions between the pleura pulmonalis and 
costalis. Abdominal viscera healthy. 

" Dissection of case 6th. A considerable quantity of fibrin was 
found in the cavity of the abdomen. The intestines were generally 
glued together, and the peritoneum was highly vascular. When the 
thorax was opened, the lungs did not collapse. The pleura was not 
inflamed. The mucous membrane lining the trachea, bronchia and 
air-cells, was highly vascular, and the tubes were filled with a bloody 
serum. The right auricle and ventricle contained more blood than 
natural." 

Pathological remarks on erysipelas. — Doubts have been already 
stated as to the existence of idiopathic erysipelas, when it does not 
proceed from external injury ; and I am inclined to believe that when 
it does occur after external injury, it is even then, in most instances, 
only symptomatic of some internal affection, which may be a disor- 
der of function, or one proceeding from structural lesion of some 
internal organ. Erysipelas appears to be an inflammation produced 
by one of those salutary efforts of the constitution, by which disease 
is sometimes removed or translated from one tissue to another: in 
this instance, from an internal organ to the skin, which has compara- 
tively a less important part to act in the animal economy. In point 
of fact, erysipelas ought to be regarded very much in the light of a 
natural blister. But I shall now enumerate the points on which 
these opinions rest, and afterwards proceed to adduce the evidence. 

1. The constitutional disturbance, which exists in all cases before 
the appearance of the erysipelatous inflammation, shows erysipelas 
to be merely an occasional symptom of some other diseased state of 
the system. 

2. The mitigation of the internal disturbance which frequently fol- 
lows the appearance of the cutaneous inflammation; and the repro- 
duction of perhaps worse symptoms upon the sudden recession of 
the erysipelas. 

3. The appearances on dissection. 

4. The relief afforded by treatment founded on these opinions. 

1. In proof of the first point, that constitutional disturbance exists 
in all cases prior to the appearance of the cutaneous inflammation, it 



ERYSIPELAS. 661 

may be mentioned, that I have never yet seen a case of erysipelas, 
however slight, which was not preceded by constitutional symptoms. 
Renauldin, in his short but able article on erysipelas, in the " Dic- 
tionnaire des Sciences Medicates" in giving an account of the symp- 
toms and march of the disease, says, « It is rare that idiopathic 
erysipelas manifests itself, without having been preceded by some 
phenomena which denote an approaching alteration of health. But 
these precursory signs, being common to many diseases, do not an- 
nounce an erysipelatous eruption, more than another of the exan- 
themata, or some other fever. It is thus that a person feels wandering 
pains in the limbs, spontaneous lassitude, cold, shivering, agitation, 
anxieties, and is generally out of order; he soon complains of disgust 
at food, nausea and inclination to vomit, violent headache, want of 
sleep;— a burning heat succeeds to the cold, and spreads over the 
whole body," &.C 

In the previous page, in speaking of idiopathic erysipelas, Renaul- 
din appears to entertain the same opinions that are here advocated; 
for, in his division of erysipelas into different kinds, he states, that 
the following division, which he has borrowed from Burserius, ap- 
pears to him much more natural and useful than any other: " 1. 
Idiopathic erysipelas, primitive or essential, that is to say, that which 
takes place spontaneously, without having been preceded by any 
other malady, and which is produced by an internal cause {et qui 
nait d'une cause interne.) 2. Symptomatic or secondary erysipe- 
las, which depends upon another affection, and goes through its 
course with it: as phlegmon, oedema, every kind of continued fever, 
and different internal affections, sometimes of an acute, sometimes 
of a chronic nature. 3. Accidental erysipelas, which is occasioned 
fortuitously by a manifest external cause, acting immediately upon 
the skin; as the scorching rays of the sun, a superficial scald, the ap- 
plication of cantharides, or any other acrid and irritating substance, 
injuries, ike." 

Cnllen has given the following history of the symptoms: — "Ery- 
sipelas of th" face comes on with a cold shivering, and other symp- 
toms of pyrexia. The hot Stage of this is frequently attended with 
aconfiiMon of head and Borne degree of delirium; and almost always 
with drowsiness, or perhaps coma. The pulse is always frequent, 
and commonly full and hard. When these symptoms have continued 
for one, two, or at most fhree days, there appears on some part of 
the face a redness, &c (Vol. i. p. 255.) Although Cullen specifies 
"erysipelas of tin; lace," yel it is well known that this affection, 
attacking any other pail of the body, is preceded by a similar train 
of symptoms. 

Sydenham, in his letter on the plague of 1685 and the following 
year, observes, " that erysipelas Ih'inui much in the same manner as 
the plague, viz.: with a shivering, followed by a feverish heat; so 

that those who never had the disease before think' it is the plague, 
till it fixes itself in tin.- leg or some other part." 

These paragraphs an: purposely introduced, in order that I may 
not be inspected, by those who are yet inexperienced, of having 



662 ERYSIPELAS. 

dressed up a statement of the precursory symptoms to suit my own 
purposes. 

Cutaneous inflammation, produced by a blister or a scald, will 
most undoubtedly excite general irritation, and more or less fever. 
In this case we have ocular proof to guide us; but in erysipelas we 
have the general commotion of the constitution first, which I have 
known to continue for ten, or twelve, or thirty days before the ery- 
sipelas appeared. 

Cullen himself does not seem to have been well satisfied with the 
prevailing doctrines respecting erysipelas. In describing the different 
species of this affection, at page 75 of his Nosology, after mentioning 
the erysipelas pestilens of Sydenham, he observes, in a note, "This 
and the following species (erysipelas contagiosum) seem to be nothing 
but fevers with a symptomatic erythema;" and I find, in the next 
page, that Cullen entertained doubts regarding the idiopathic nature 
of several other cutaneous affections. Treating of miliary fever, for 
instance, he says, "That it is never idiopathic, I dare not affirm, in 
opposition to the opinion of all physicians from the middle of the 
seventeenth century to the present day, and contrary to the senti- 
ments of some respectable modern physicians: but, as I know that 
experience, in this case, is often fallacious, and that physicians, for 
the most part, are but a herd of imitators, I am forced to remain 
doubtful." 

No one can have been any length of time in practice without 
having met with instances of erysipelas occurring in individuals 
whose constitutions were destroyed by long-continued indulgence at 
table and drunkenness— in whose bodies there were abundant evi- 
dences of functional or structural disease of many important viscera; 
therefore, it is unnecessary to quote cases in proof of this. 

That this disease frequently occurs during the progress of severe 
internal disorders, the records of medicine fully prove; several cases 
in my own practice have been already mentioned, when describing 
the appearances found on dissection, and similar cases have been 
quoted from Gartshore and Underwood. In addition to these facts, 
it may be mentioned that the late Dr. Gordon, of Aberdeen, in his 
able work on Puerperal Peritonitis, published in 1795, states, (at 
page 75,) that "one of the most favourable symptoms is an erysipelas 
on the extremities, or abscesses on different parts of the body; for 
such are certain signs of a salutary crisis." And in a note, (at page 
58,) he observes: "This critical erysipelas most commonly fixes on 
the extremities, but, in a few instances, on the external surface of 
the abdomen, which happened in a case of puerperal fever which 
I attended in the year 178S. The case alluded to is the wife of 
William Walker, at Newbridge, whom I attended at the same time 
with Thomas M'Roberts' wife, whose history is given in Case VI. 
In both cases the crisis was by an erysipelas, which, in the latter, 
fixed on one of the upper extremities, and, in the former, on the 
integuments of the abdomen." 

Cullen, in treating of pneumonia, states that "sometimes the dis- 
ease disappears on the second or third day, while an erysipelas makes 



ERYSIPELAS. 663 

its appearance on some external part, and, if this continue fixed, the 
pneumonic inflammation does not recur." (Vol. I. page 149.) 

When treating of hepatitis, Cullen also observes that it "would, 
seem to be sometimes cured by an erysipelas appearing in some 
external part. (Vol. I. page 171.) 

From the repeated observations of such facts, I cannot avoid con- 
sidering erysipelas in the light of a natural blister ; and it is very 
probable that the ancients were first led to apply external irritants 
and the actual cautery, by observing the beneficial effects of erysipe- 
latous inflammation occurring under severe internal disease. 

2. The second point of evidence on which these opinions are 
founded, is the mitigation of the internal disturbance which frequently 
follows the appearance of the cutaneous inflammation ; and the re- 
production of bad, nay, perhaps, of worse symptoms, than had pre- 
viously existed, upon its sudden recession. 

These facts are so often witnessed, that I feel obliged to receive 
them as a part of the medical evidence of the case. 

Sydenham's third reason for considering erysipelas to resemble the 
plague, is, u The expulsion of the malignant matter to the skin on 
the third or fourth day, with an abatement of the symptoms." 

Hoffman, in treating of erysipelas, observes, that " it sometimes 
exhibits a manifest mark of health; other diseases, especially a con- 
vulsive asthma, and a convulsive colic, have been removed by an 
attack of erysipelas." In another passage he states, " But those 
who die of this disease, are carried off by a fever, which is mostly 
joined with a difficulty of breathing — sometimes with a delirium — 
sometimes with drowsiness, &c." — The same author again remarks, 
that " it is rendered very dangerous by improper treatment. I have 
seen erysipelas strike in, after taking a vomit and a strong purgative, 
when an inflammation of the stomach, and death, have followed. 
Bleeding also has struck it in, and rendered it wandering with much 
greater inconvenience. I have also observed, that after being re- 
pelled in the leg, by an application formed of camphor, red lead, and 
bole, it has been followed by a high fever, and intolerable pail) of 
stomach, a great difficulty of breathing, bilious vomiting, loss of 
Strength and appetite. — These symptoms have not gone oil', till the 
erysipelas had been invited back to its former seat by a blister and 
antispasmodics and mild Slldorifics; and 1 certainly know, (continues 
Hoffman,) that an erysipelas of the head, having been treated by 
repellent, cooling, binding, or too spirituous applications and cam- 
phorated liniments, baa brought on a vertigo, lethargic disorders and 
quinsey, delirium and palsy of the tongue; which evils have fre- 
quently proved fatal to persons in years, and scorbutic habits." 

"A gentleman," says Dr. Swain, the accomplished translator of 
Sydenham's works, "who, by the cold air, suddenly struck in the 
erysipelas of his face, had all the symptoms of an inllanunalion of 
the brain, rind was in the most imminent danger, appeared to be 
snatched from death by bleeding in the jugular vein, and besides 

that, applying two large blisters to both sides of his neck, bleeding 

him in the arm, and giving him a strong purge, all which was done 
in the space of an hour." 



664 ERYSIPELAS. 

Mr. Abernethy noticed a case of this kind in his lectures. "A 
stout healthy young man had an attack of erysipelas on his hand; he 
plunged it into cold water, and was soon seized with insensibility; he 
fell down in a state of torpor, and soon died." 

This gentleman is also represented to have said, in his lectures, 
"I'll be hanged if erysipelas is not always the result of a disordered 
state of the digestive organs. I never see it come on if the digestive 
organs be right, and it goes away as soon as they are put right. Now 
what is the medical practice? they powder the part a little, and they 
give bark, and so on !! " 

" It has been observed," says Wilson Philip, in his work on Sim- 
ple and Eruptive Fevers, Vol. I. page 362, " that if the typhus has 
commenced before the appearance of this eruption (erysipelas,) the 
symptoms of synocha are often recalled by it. They are not only re- 
called but maintained ; for the typhus, which supervenes towards the 
end of an erysipelatous fever, is less considerable, in proportion to 
the preceding symptoms, than in other varieties of synochus." And 
at page 367, he observes : " Besides, the erysipelatous, like other 
eruptions which appear in continued fevers, has been known sud- 
denly to recede; an alarming train of symptoms, of which debility is 
the characteristic symptom, supervene." In another place, he also 
remarks: "This is also to be remembered, that when retrocession 
takes place, the patient is seldom out of danger till the eruption is 
recalled, which is done with greater difficulty the more he is debili- 
tated." 

It may be said that the appearance of the erysipelatous inflamma- 
tion does not always produce mitigation of the internal disease. The 
simple answer to this objection is, neither does an artificial blister, 
applied for the express purpose of translating the diseased action to 
the surface, which I maintain the erysipelas is intended by nature to 
effect. In severe inflammation of an internal organ, a blister, how- 
ever large, has but little effect, if applied before the disease is very 
much subdued by depletion. In like manner, I may be allowed to 
say respecting erysipelas, that if the internal disease exist in a greater 
ratio than the cutaneous inflammation, then little or no constitutional 
relief can be expected. 

At the period when the erysipelatous inflammation begins to 
decline, particularly under improper treatment, it is frequently ob- 
served that the functions of the brain or lungs, or perhaps both, 
appear to become suddenly and seriously affecled, accompanied by 
oppression at the prascordia, and other alarming symptoms. In such, 
circumstances, it is said, in ordinary medical language, that the 
disease has spread, or extended itself from the skin to internal 
organs; others speak of it as a translation or metastasis. Cullen 
denied the doctrine of translation, and was rather inclined to adopt 
the idea of the extension of the inflammation. Thus, when the 
erysipelas attacks the head, and when the brain becomes affected, 
it is said to be in consequence of the extension of the inflammation 
through the contiguous parts. There can be no doubt that a fair 
translation does occasionally take place in inflammatory complaints, 
particularly when connected with erysipelas ; so much so, that we 
actually find a variety of erysipelas in the books, termed " errali- 



ERYSIPELAS. 665 

cum." In general, however, attentive observation has long con- 
vinced me, that in erysipelas, diseased action had existed in the in- 
ternal organ before the external inflammation appeared, during what 
may be termed the eruptive fever, and that when the cutaneous in- 
flammation occurred, acting the part of an effectual contra-irritant, it 
mitigated, but did not altogether remove the original disease. In 
erysipelas, the attention of the patient and also of the practitioner is 
attracted by the burning heat and pain of the external inflammation; 
but the internal disease becomes again apparent when the effect of 
the external inflammation subsides. Here again we cannot fail to 
discover additional proof of the analogy between a natural and an 
artificial blister. 

Before quitting this part of the subject, a few remarks may be 
made regarding the mitigation of symptoms upon the appearance of 
the erysipelas, although it is repeating nearly the same observations 
which were made in the first volume, when treating of the General 
Pathology of Eruptive Fevers. The relief will not strike the eye 
of a symptomatica! physician, who cannot see the pathological miti- 
gation of symptoms, because the patient, who may have been pre- 
viously lethargic or comatose, now complains most vehemently. 
Formerly there may have been little complaint, and little or no 
febrile movement; now, however, there may be great anxiety, rest- 
lessness, pain, with febrile symptoms well developed ; but upon 
minute examination of the particulars of a case of simple erysipelas, 
these will be found to depend principally, if not entirely, upon the 
external inflammation. Here again we observe the analogous effects 
of a common blister, which very frequently aggravates the patient's 
Buffering, while it is mitigating the disease. 

3. The third point on which these doctrines are founded, is the 
appearances found on dissection; and a triumphant appeal may be 
made to those dissections which are already recorded under the 
proper head. I may here take an opportunity, however, of shortly 
stating the appearances found in the brain of a man affected with 
erysipelas, a respectable spirit dealer was taken into the surgical 
hospital, affected with spontaneous erysipelas of ilie right arm; he 
had been several days ill. When Mr. Syme Baw him, (here were 
Bymptoms indicating violent inflammation of the brain. Immediately 
before my visit, (he diseased pari had been scarified, from which 
twelve ounces of blood were abstracted. The inflammation on the 
forearm was severe, bul above the elbow it was superficial, and did 
not extend quite to Ihe axilla. He was continually talking, and 
could scarcely be restrained in bed, declaring he wanted to i>c up, 
for he had no complaint whatever; his eye was bright and lively; 
tin- expression of countenance displayed no signs of sinking; tongue 
parched and furred towards the root ; pulse 98, and soft ; consider- 
able rigidity of the flexor muscles of the right arm. We were of 
• .pinion, iii.it tin' man was m great and immediate danger ; but more 
limn the inflammatory actiou in the brain than from the erysipelas. 
The head was order< I to be shaved, and cold applied. Before this 
was done, he beci • more furious, and continued so till within an 

hour "i his death, during which short period he was comatose ; tho 
56 



666 ERYSIPELAS. 

rigidity was observed to take place in both arms, and to increase till 
the time of his death. After great difficulty the friends agreed to 
allow the head to be examined, but the head only ; and, as had been 
predicted, great vascularity was discovered in the membranes of the 
brain, but particularly at its base ; the brain itself was generally soft, 
especially the middle lobes, and more particularly still, the corpora 
striata, and especially that on the left side, which was reduced into 
a state of complete ramollissement; the white substance of the brain 
was generally of a brownish hue — an appearance which is known 
to be produced when its vessels contain much blood. A small 
cavity, containing a minute portion of blood, was found in the sub- 
stance of the middle lobe on the left side. 

4. I have now to bring forward a most important part of the evi- 
dence in proof of the views here advocated, viz.: the relief afforded 
by proper practice. 

Treatment of erysipelas. — It is truly lamentable to reflect how 
fatal erysipelas has always been, and continues to be, not only in 
public hospitals, but in private practice. It is not my intention, and 
certainly it is not my interest, to give offence to any one, but I cannot 
resist expressing an honest opinion, that much of this fatality is the 
result of bad practice, founded upon erroneous pathological notions, 
or, perhaps, if one may be allowed to judge from the vacillating 
measures too often employed, upon no fixed notions whatever. 
When engaged in lecturing or in writing, I think myself bound in 
duty, as well as in honour, to adopt the maxim of Aristotle, when he 
said, " Plato is my friend, but truth much more." However highly 
a medical man may be respected, and whatever friendship may be 
felt towards him, such circumstances will, I trust, never prevent me 
from expressing an opinion respecting any particular view or mode 
of practice which he may pursue, particularly when it is destructive 
to human life. 

Many of my medical acquaintances are as much afraid of erysipe- 
las as they would be of the plague : others, from the dread of typhoid 
symptoms, and of mortification and putridity, aggravate the disease 
by improper remedies. 

The symptoms which are called typhoid are often the consequence 
of the intensity and depth of the external inflammation, running into 
extensive destruction of parts, by diffuse suppuration and mortifica- 
tion. This cannot be denied; and when the case arrives at these 
stages, patients have but little chance of recovery under any plan 
of treatment ; but the question comes to be, How are these bad con- 
sequences to be prevented in subsequent cases? The answer is easy, 
and the practice simple, provided medical men would use the com- 
mon sense with which they are endowed, and give up a prejudice 
that has been inculcated on their minds from the earliest period of 
their lives — forgetting that there is any thing mysterious in erysipe- 
las—and learning to treat each case that comes before them upon its 
own individual merits. 

Some take large quantities of blood, indiscriminately from every 
patient, because they have seen the practice successful in one or two 
instances. Others give the most powerful stimulants and tonics in 



ERYSIPELAS. 667 

every case, because they have seen that plan succeed in a few instances. 
A third set depend upon opiates, or some other one particular reme- 
dy. A fourth class will be found to draw blood, but not in sufficient 
quantity, and perhaps they repeat the operation in small quantities 
without mitigating the disease, while they do great harm by debili- 
tating the patient; and in order to counteract this they give stimu- 
lants too soon. Some timid practitioners will be found to do nothing 
but to keep open the bowels, and sprinkle the diseased part with 
flour. Often have I had occasion to commiserate the wretched pa- 
tients, who with dry, parched tongues, were doomed to swallow 
beefsteaks — and others, consumed by burning thirst, compelled to 
take wine and even brandy ! Some practitioners make incisions into 
erysipelatous parts in all circumstances, while others decry the prac- 
tice, except when matter is formed, as in phlegmonous erysipelas. 

Typhoid symptoms, besides being produced by mortification, and 
extensive destruction of the affected parts, are frequently occasioned 
by the continuance or concentration of acute or chronic diseased ac- 
tion in a vital organ, as seen in the cases already recorded under the 
head u Appearances on dissection." The next question comes to 
be, after this information is obtained, How can these results of dis- 
eased action be prevented in subsequent cases? The answer is neither 
so easy, nor the practice so simple, as in the case of the external in- 
flammation, where that only has to be subdued; because it is now 
fully established that erysipelas occurs complicated with a great many 
diseases of internal organs, and that inflammation of these (even of 
the brain itself,) may go on, and be beyond the reach of art, without 
exciting such violent symptoms as to make the patient or his friends, 
nay, even some medical men, aware that his life is in the least dan- 
ger. 1 cannot but agree with my late lamented friend Dr. Arm- 
strong, when he stated that "pure surgery is like a vampire, whose 
daily food is human blood," and deprecate the conduct of those pure 
surgeons who boast of enjoying immense wealth from medical, as 
well as BUrgical practice. and at tiie same lime do not blush to confess 
their ignorance of what may be called medical pathology,; nay, who 
even decry every part of the profession bill the practice of pure sur- 
gery. W'nh regard to ihe great doctors of Lond.ni, Mr. A.bemethy 
used to tell his pupils what they do and say about erysipelas. "I 
will tell you (said he) what the doctors say about that ; they say you 
had better not meddle with it at all. Yon may powder it a little if 
you please, but do not attempt to repel it, for if you do, you will 
have it affect BOme other part, perhaps some affection of a vital or- 
gan may take place. Now this is true enough, (continued he,) for 
if you try to drive it away, if you put on your cold washes, or play any 
of your BUrgical tricks, why, you have a metastasis, as they call it, and 
the man M. 

G id bleeding was practised in erysipelas by Sydenham, and 
has since been followed by many practitioners; but either they have 
not been able to support the practice by .sound reasoning, or bleed- 
ing has hern injudiciously employed, and ins therefore frequently 
n into disrepute. Bateman says, m Ins Synopsis, page 131, 
" Blood-letting, winch has been recommended as the principal re- 



668 ERYSIPELAS. 

medy for the acute erysipelas, is seldom requisite; and un]ess there 
is considerable tendency to delirium or coma, cannot be repeated 
with advantage, at least' in London and other large towns." "Ve- 
nesection (says Mason Good) was formerly recommended, and has 
been so of late by few ivriters, but upon mistaken principles. I can 
conceive few cases in which it can be serviceable, and the applica- 
tion of leeches always exasperates the efflorescence." 

I know no remedy so decidedly and immediately efficacious as 
general bleeding, if it be performed sufficiently early iti the attack, 
and in constitutions not greatly debilitated by previous disease or 
bad habits: whereas, nothing but bad consequences can be expected 
to result from general bleeding in erysipelas, when the disease, hav- 
ing passed its first stage, is about to terminate in extensive suppu- 
ration, or in gangrene, or when it has taken place towards the ter- 
mination of an acute or chronic inflammation of a vital organ, or at 
the termination of fevers. General bleeding may be attended also 
with bad consequences when employed in the following circum- 
stances: 1. When the bleeding is not carried far enough to arrest 
the disease, at the same time that it destroys much strength. 2. When 
not followed up at a sulficiently short interval by a second general 
bleeding — a local abstraction of blood— or by purgatives, contra- 
stimnlants, &c. 

In the year 1824, I was requested to see a young man, residing 
near Leith Fort, who had part of the leg and the whole of the thigh 
affected with erysipelatous inflammation, the disease rapidly extend- 
ing over the abdomen. The part affected was very red, painful and 
tumefied. The constitutional symptoms were severe. The disease 
was attributed to his having knocked his knee against the edge of a 
grate ; no contusion was to be perceived, but he stated, that for some 
time he had been unwell, feeling drowsy through the day, and rest- 
Jess at night, being often chilly, with want of appetite, and other 
symptoms of impaired health. He had been thus affected for per- 
haps ten days or a fortnight before the slight accident. 

A vein was immediately opened, and about twenty ounces of 
blood abstracted, when a tendency to syncope took place, and the 
arm was tied up. Upon looking at the inflamed part immediately 
after the bleeding, no trace of redness conld be observed, except in a 
circle of about two inches round the part on which the blow had 
been received. Dr. T. P. Lucas, now in the royal artillery, who 
was present at the time, cannot forget the impression this case made 
upon his mind. The treatment was followed up by antimony, laxa- 
tives and the antiphlogistic regimen. A small abscess was opened 
in the course of two days after the bleeding, and the patient made a 
rapid recovery. 

A hard-working woman, aged 70, frequently much exposed dur- 
ing laborious occupation as a water-carrier,* was seized in Decem- 
ber, 1S23, with what she called a severe cold. Her voice was al- 
tered ; she had a cough, severe headache, sickness and oppression at 
the prascordia, together with constant chilliness. These symptoms 

* The last of her class— the old "water cadies" of Edinburgh. 



ERYSIPELAS. 669 

existed for some days, attended by loss of appetite and want of 
sleep; but she thought they would wear away. At length she felt 
heat and acute pain in the integuments of the upper part of the face 
and head; general swelling soon followed, severely affecting the 
ears, which were quite hard to the touch. Even those symptoms 
were allowed to continue for three days, before she applied to my 
dispensary for advice, when, at length, the symptoms became alarm- 
ing, and the night previous to my seeing her, she was delirious. I 
found her labouring under great headache, general oppression and 
fever. The skin was hot and dry; tongue loaded; thirst; pulse 
quick and hard; together with considerable prostration of strength. 
One of my pupils (Dr. Henry Lucas) was requested to bleed her to 
the near approach of syncope; but not having succeeded in making 
a large orifice, and being, perhaps, rather afraid to take away much 
blood from a woman of her advanced age, he did not bleed her so 
as to make any impression on the disease, or upon the constitution; 
but he came immediately to inform me of his proceedings. Another 
gentleman, who was further advanced in the profession, (Mr. Mun- 
ro,) returned with Dr. Lucas, and bled the patient till syncope took 
place. The swelling and redness of the parts immediately disap- 
peared ; the thickening of the ear only being left, but which went off 
in the course of a day or two. The general oppression, fever, &c, 
were also immediately subdued— passage was obtained from her 
bowels before bed-time, when she got a large opiate; she passed a 
good night. A solution of tartrate of antimony was given to act as 
a contra-stimulant, but of this she took only two doses. In four days 
she was convalescent, walking about the house ; and made an excel- 
lent recovery. 

Many important cases could be quoted showing similar results, 
even in some instances where fears were entertained that the disease 
had advanced too far, from the appearances of debility under which 
the patients laboured. I have never experienced bad effects from 
opening a vein; but care has always been taken to restrict (he 
employment of this remedy according to the circumstances already 
noticed. 

The application of leeches upon the inflamed part stands next in 
importance to general bleeding. Their number is to be regulated 
by the age and constitution of the patient, and also by the intensity, 
extent and duration of the disease: — to an adult with ordinary 
strength, 1 would scarcely think of applying fewer than twelve or 
eighteen. This practice I have been in the habit of adopting ever 
since the year 1811, and with uniform success. But I apply them 
only when the disease is in its first stage, and, contrary to the predic- 
tions of many individuals, neither ulceration nor mortification has 
ever ensued. Medical Lrentlemen have seen the patients twenty-four 
hours after the application of leeches, when they could scarcely see 
marks of the bites. Previously they did not believe that any except 
bad consequences ppsJd ensue from such practice. 

The application of leeches possesses advantages over scarifications 
HI the first stage of erysipelas, and before either hardness of the skin 
or suppuration has taken place. More blood can be evacuated by 

56* 



670 ERYSIPELAS. 

the leeches, unless the incisions be made very deep, and patients will 
be more easily persuaded to allow the application of the leeches than 
to have scarifications made. But, in the other circumstances already 
mentioned, viz.: the hardness of the part, or the existence of matter, 
the knife is to be used in preference. Should suppuration have taken 
place beneath a fascia, the incisions ought to be extensive, in order 
to give it free vent; but I have seen profuse haemorrhage, on several 
occasions, from punctures, which could not be restrained. The pa- 
tients would, I believe, have died of the disease in any circumstances; 
but they began to sink immediately, and never recovered the loss of 
blood. In one of these patients the part was carefully examined by 
the late Dr. Dease, surgeon to the forces, and Mr. Marshall, now 
assistant surgeon in the 87th regiment, and, I believe, my learned, 
and facetious friend, the late Surgeon Martindale, of the 17th foot, 
with a view to discover if any large vessel had been wounded, but 
none could be found. Indeed, we thought it would be so, and that 
the dark-coloured blood, which flowed in a large stream from the 
wound, had been previously effused into the cellular tissue. 

It is necessary to obtain free motions from the bowels, at first, by 
purgative medicines, and this may be subsequently effected by the 
use of antimony, which cannot be too highly extolled, from the effects 
it produces as a contra-stimulant in this disease. It is a remedy 
which may be frequently trusted to exclusively in very slight cases 
of erysipelas, where there are no headache, delirium, difficulty of 
breathing or oppression at the prsecordia, no pain on pressure in the 
abdomen, and no diarrhoea. The reader will, therefore, perceive 
that I neither think it necessary to bleed nor to apply leeches, unless 
compelled by the constitutional symptoms, or the severe pain in the 
inflamed part. In many cases, which fall under my notice, where 
an internal organ is suffering from diseased action, I trust to the 
leeches, without having recourse to general bleeding, particularly 
when afraid that the disease may be too far advanced for the lancet. 

Opiates are often of considerable benefit in erysipelas, although 
they have aggravated the external irritation in several instances in 
which they have been prescribed, and particularly in one case where 
the disease affected the whole body. The use of opiates appears 
to be most advantageous in cases which have passed into suppu- 
ration or mortification, but in which there is no tendency to coma. 
Some practitioners have great faith in emetics ; but they seem to be 
serviceable in very recent cases only, where the disease depends 
upon some acrid or indigestible substance taken into the stomach ; 
and, by the "speedy evacuation of which, the progress of the erysi- 
pelas will, in many instances, be checked. 

Blisters applied to the part affected have, I understand, been much 
used in France, where they are highly extolled ; but I cannot speak 
from my own experience of them. 

With respect to tonics and stimulants, there can be no doubt of 
the great advantages occasionally derived from their employment in 
certain cases where the disease is so far advanced before medical aid 
is obtained that the strength and vital powers have begun to sink — 
where suppuration has taken plaee, and the matter already evacu- 



ERYSIPELAS. 671 

ated— or where dead parts are undergoing the process of separation 
from the living. 

The best local applications are warm fomentations in the first in- 
stance, and should the part show a tendency to suppurate, light poul- 
tices may be applied alternately with fomentations. Cold astringent 
applications and evaporating lotions will sometimes be found to 
soothe the patient's sufferings, by removing the pungent heat for the 
time. 1 would recommend, however, that they should not be used 
until the bowels have been well opened, or till bleeding and other 
antiphlogistic means have been employed. Speaking of cold appli- 
cations, Renauldin declares they ought to be entirely proscribed, and 
that he could cite many examples of their baneful effects; and he 
actually quotes such instances on the authority of Hagendorn, 
Hoffman and Fabricius ab Aquapendente.* In truth, it will be 
seen, from the preceding statements, that erysipelas must be treated 
upon very different pathological principles from those stated in the 
London Medical and Physical Journal, by Mr. Earle, who considers 
erysipelas to be "essentially an affection of t lie skin." I shall 
continue to quote the opinion of this clever surgeon till he adopts 
wiser views, should he continue to anathematize me in every num- 
ber of the Medical Gazette. 

» Diet, des Sciences Med., p. 267. 



CHAPTER III. 
PAPULAR DISEASES. 



Under this head I shall speak of the diseases which Willan lias 
termed Strofulus, Lichin, and Prurigo, without splitting them into 
the same number of varieties. 

Willan has divided strofulus into five species, viz.: S. intertinctus, 
S. albidus, S. confertus, S. volaticus, S. candidus; but I shall not 
treat of them separately, because they are not, even according to 
Bateman, "very important objects of medical practice." 

With respect to the second class, lichen, I shall speak of it also 
under one head, as Bateman himself admits that "there is scarcely 
any limit to the varieties of these papular affections." Were I to 
follow the artificial classification, I should have to treat of Lichen 
simplex, L. pilaris, L. circumscriptus, L. agrius, L. lividus, L. tropi- 
cus, L. urticatus. 

As to the third class of this order, I shall describe only one variety, 
prurigo, instead of four or five, as the same treatment is to be fol- 
lowed in all, whether it occur in youth or old age, upon the neck or 
pudenda muliebris. 

By the term papular eruption, a number of small elevations under 
the cuticle is meant, generally having an inflamed base, sometimes, 
although seldom, containing a fluid, or suppurating, and commonly 
terminating in desquamation of the cuticle. 



STROFULUS. 

Strofulus is a papular affection of the skin, to which infants aud 
children are liable, and, in common language, is known by the term 
"gum;" — if it is reddish, it is called "the red gum," if whitish, the 
"white gum," and so on. It is a form of eruption depending either 
upon irritation in the primae viae, or upon teething, and is most 
commonly met with in those infants who are fed with the spoon too 
early. 

Treatment of strofulus. — I have always observed that those 
children thrive best, and have fewest complaints, who get least 
physic, and who are brought up at the breast ; 1 would therefore 
strongly recommend, that, in general, spoon-meat should not be 
given to children for the first three months, and physic as rarely as 
possible. Should this eruption appear, care must be taken not to 



PAPULAR DISEASES. 673 

expose the patient to cold or damp air, and ablutions with tepid 
water are to be had recourse to twice a day. When the child is 
asleep, it should not be covered with too many bed clothes : and 
should it appear during the period of dentition, the gums must be 
scarified occasionally. If fever takes place, the usual remedies 
should be exhibited, and the diet regulated. 



This disease is to be regarded as strofulus occurring in adults. 
Dr Willan has defined it, "an extensive eruption of papulae affect- 
ing adults, connected with internal disorder, usually terminating in 
scurf; recurrent, not contagious." I have no doubt that the differ- 
ent varieties of lichen depend partly upon gastro-intestinal irritation, 
and partly upon determination of blood to the surface, as occurs dur- 
ing cold weather, and when the body is over-heated, either by too 
much clothing or violent exercise. The great characteristic of the 
disease is tingling or itching, aggravated upon going to bed; and 
the purest example of it is to be found in that variety which is called 
" prickly heat." It sometimes occurs in old age, when it is attributed 
to debility of constitution, which, I am convinced from experince, is 
not so frequently the cause as indigestible food. 

Treatment of lichen. — Regular attention to the bowels, avoiding 
every acrid and indigestible kind of food, and violent exercise, toge- 
ther with the use of the tepid bath, and the local application of com- 
mon vinegar, or the juice of limes, constitute the treatment. 



This is a disease resembling lichen, excepting that the papula? 
possess more of a chronic than an acute character, and that the itch- 
ing is more violent and intolerable; indeed, I have considerable 
doilbtfl whether it ought not to be considered as an aggravated form 
of lichen. The chief forni under which we see the complaint, is, in 
ft- males, in and about the labia pildendi; the desire to relieve the sen- 
sation by scratching is very difficult to suppress, and it is increased 
by exposure to heat, the action of walking, &c. It may be produced 
in this region of the bfdy by the causes already mentioned when 
treating of lichen, as also by ascarides in the rectum, and the acrid 
nature of discharge! from the vagina. 

Treat ment of 'prurigo. — The general principles of treatment must 
be the same as tnose described under the last head, with the follow- 
ing additions, when it attaek-s the parts of generation — viz.: frequent 

ablutions, sometimes using astringent washes, and occasionally throw- 
ing them into the vagina; and if there he much irritation and swell- 
ing, the recumbent posture is very necessary. In such eases, par- 
ticularly when the inflammation of the part runs high, I have seen 
tie' best effects from one general bleeding. If ascarides in: suspected 
to exist in the rectum, enemata with turpentine should be employed. 



674 PAPULAR DISEASES. 

In extreme cases, when the parts are very tender, considerable be- 
nefit has been derived from the application of a solution of the 
nitrate of silver to the part, of the strength of six grains to the ounce. 
An alterative course of mercury, either in the form of blue-pill, or 
that which goes under the denomination of Plumber's, is sometimes 
beneficial, as is also Harrogate water. A minute examination 
should be made to ascertain if any pediculi exist, which often 
create intolerable itching and red papular elevations. The best 
method of destroying these is by applying a little calomel, mixed 
with hog's lard; the precipitate produced by throwing calomel into 
lime-water; or a little mercurial ointment. 



CHAPTER IV. 
PUSTULAR DISEASES. 



In this class I shall treat of Impetigo, Porrigo, Scabies, Ecthyma, 
Rupia, Acne and Sycosis. The last two have been included by Wil- 
lan in his seventh order Tubercula; and I have excluded one disease 
which he lias comprehended in his order Pnstnlae, viz., variola, be- 
cause it ought to be classed among the fevers with eruptions, where 
1 have placed it in the first volume. 

A pustule is known by an elevation of the cuticle, with an in- 
flamed base, containing pus, which is formed sooner or later, it" t tic 
disease be not cut short. 



IMPETIGO. 

Impetigo may be regarded as a pustular eruption, the pustules 
being small, irregularly circumscribed, with but a slight elevation of 
the cuticle, and terminating in scabs. It is produced and accom- 
panied by active inflammation and considerable irritation of the parts 
affected, which terminate in a chronic action of the vessels en- 
gaged in the disease. In the first stage, the eruption is vesicular, 
but, like small-pox and other similar diseases, it becomes pustular, 
and terminates either in the formation of scales, presenting an ap- 
pearance like lepra vulgaris and /isoriusis, or when there is a 
number of pustules accumulated in one part ; the matter is discharged, 
and dries, forming extensive scabs, which irritate the surrounding 
parts, particularly if removed incautiously. Willan and Bateman 
describe live varieties, viz.: Impetigo igurata — I- Bpatsa — I. erysi- 
pelatodes — I. seabida — I. rodens; four of which differ from each 
other only in the intensity and extent of the diseased action and the 
Shape and distribution of the pustules; and they seem to have con- 
founded this disease with scabies. Their fifth variety, tin; u Impetigo 
rodens" Bateman admits in' has never seen, bM describes it to be 
a cane, runs ulceration extending deeply and extensively, and which 
is said to commence with a cluster <>r pustules. Impetiginous dis- 
orders are not ne cessa rily accompanied by fever, neither are they 
contagious, nor, u is said, communicable by inoculation. 

Causes ';/ impetigo.— -Dr. Willan believes that tins disease is fre- 
quently preceded by Constitutional disorder, SllCh as pains in the 
bead and stomach ; but Mr. i'iuinbc is of opinion, that when these 



676 PUSTULAR DISEASES. 

exist, they are owing to accidental circumstances; and that the dis- 
ease is always occasioned by local irritation, such as the application of 
alkali to the skin, &c. My experience leads me rather to agree with 
Dr. Willan, admitting, at the same time, that the exciting cause may 
be, in many cases, fairly attributed to the local application of sub- 
stances which irritate the skin, as sugar, lime, pepper, &c, but which 
would produce no local effects were the constitution not strongly 
predisposed to cuticular inflammation. The predisposition is, in 
general, to be sought for in the condition of the mucous membranes, 
and sometimes in the functions of the liver, kidneys, &c. 

Treatment of impetigo. — Fomentation, when there is much in- 
flammation, together with the tepid bath, gentle laxatives repeated 
da ; ly, attention to the diet, and avoiding irritating the part by 
scratching, and the rough or incautious removal of the scabs, are all 
points of importance. At the same time, care should be taken to 
avoid even a chance of the reapplication of the irritating cause. Iu 
the acute stage, I have often seen it serviceable to take a little blood 
from the part, either by means of a fine pointed lancet, or a sharp 
needle; and if pus be formed, it may be evacuated by the same 
means with benefit. When the inflammation becomes chronic, 
stimulating and astringent washes may be used, such as lime-juice, 
common vinegar, solutions of the sulphates of zinc, alumina, or cop- 
per, or even, what is still better, if there be much pain and irritation, 
of the nitrate of silver. Cases may occur in which certain well- 
known ointments, as those of the acetate of lead, nitrate of mercury, 
&c., may be found useful ; but I have generally observed that greasy 
applications rather retard the cure. 



Porrigo is a contagious pustular disease, which principally affects 
the young, and may be divided into two kinds, one of which is mild, 
depending upon some constitutional irritation, and affecting the head 
and face of children who are generally of a full habit of body. The 
other variety affects the scalp, often extensively, and is, in particular 
constitutions and in circumstances of neglect, very intractable. 

I shall first treat of all the mild varieties, under the term porrigo 
larva/is, (commonly called crusta lactea,) for, notwithstanding what 
has been stated by authors, the affection ca'led porrigo larva/is, and 
porrigo favosa, differ so very little, either m their causes or in their 
appearance, that I consider it unnecessary 10 give a separate descrip- 
tion of each. 

I shall afterwards notice the true ring-worm of the scalp, which is 
termed by some authors simply porrigo, by others P.furfurans, P. 
lupinosa, P. scutulata. 

"The porrigo (says Bateman) is a contagious disease, principally 
characterized by an eruption of the pustules, denominated favi 
achores. unaccompanied with fever. The several appearances which 
the disorder assumes, are reducible to five or six specific forms. 

" 1. The porrigo larvalis, or crusta lactea of authors, is almost 



PUSTULAR DISEASES. 6,T 

exclusively a disease of infancy. It commonly appears first on the 
forehead and cheeks, in an eruption of numerous minute and whitish. 
achores, which are crowded together upon a red surface. These 
pustules soon break, and discharge a viscid fluid, which concretes 
into thin yellowish scabs. As the pustular patches spread, the dis- 
charge is renewed, and continued also from beneath the scabs, in- 
creasing their thickness and extent, until the forehead, cheeks, and 
even the whole face, become enveloped, as by a mask, (whence the 
epithet larva/is.) the eyelids and nose alone remaining exempt from 
the incrustation. The eruption is liable, however, to considerable, 
variation in its course; the discharge being sometimes profuse, and 
the surface red and excoriated — and at other times scarcely percep- 
tible, so that the surface remains covered with a dry and brown scab. 
When the scab ultimately falls off, and ceases to be renewed, a red, 
elevated and tender cuticle marked with deep lines, and exfoliating 
several times, is left behind ; differing from that which succeeds to 
impetigo, inasmuch as it does not crack and form deep fissures. 

"Smaller patches of the disease not unfrequently appear about the 
neck and breast, and sometimes on the extremities, and the ears and 
scalp are usually affected in the course of its progress. In general, 
the health of the child is not materially affected, especially when the 
eruption does not appear in the early period of lactation ; but it is 
always accompanied with considerable itching and irritation, which, 
in young infants, often greatly diminish the natural sleep, and disturb 
the digestion, whence much debility sometimes ensues; the eyes and 
eyelids become inflamed, and purulent discharges take place from 
them, and from the ears; the parotid, and subsequently the mesen- 
teric glands, become inflamed; and marasmus, with diarrhoDa and 
hectic, cuts off the patient. 

" .Most commonly, however, the disease terminates favourably, 
though its duration is often long and uncertain. It sometimes puts 
on a healing appearance for a time, and then returns with seventy. 
Sometimes it disappears spontaneously soon after weaning, 01 after 
the catting of the first teeth; and sometimes it will continue from 
two or three mouths to a jreai and a half, or even longer. It is 
remarkable, however, thai whatever excoriation may be produced, 
do permanent deformity ensues." (Bateman on Cutaneous Diseases, 
p. ISS.) 

The only additional observation I shall make respecting the por- 
r'm;i> favosa, is, thai it osjtirs in adults, particularly in females, and 
effects principally the scalp, the hair falling off, and becoming of .a 
lighter colour. In both affections, small glands in the neck and 
behind Ihe ears enlarge, and sometimes suppurate, The worel eases 

of the disease called porrigo furfiiraiis occur after levers, particularly 
the eruptive, and also when a scurfy slate of the scalp has existed 

for b considerable tune previous to the attack. 

Trial incut of I lit- miltlrr forms of pOfttgO. — As these diseases 

occur under some constitutional irritation, local applications are not 
beneficial till ihe original eauses are removed, it they depend on 
teething, great attention should be paid to relieve the irritation of 

the cuius, by dividing them freely as the teeth advance; and also 
57 



678 PUSTULAR DISEASES. 

to the diet, that it be light and easy of digestion ; as well as to keep 
the bowels in a proper state. Every care must be taken to keep the 
parts clean, and to avoid the application of all ointments, at least in 
the first stages, when there is acute inflammation. When the in- 
flammation runs high, immediate advantage may be derived from 
leeches; and I have had no hesitation in applying them to the face. 
When the inflammation is considerable, but does not run so high as 
to require leeching, benefit is obtained by bathing the parts with 
warm saturnine lotions. Should the scabs, from neglect or other 
causes, become extensive or hard, they should be carefully removed 
by means of tepid fomentations or poultices. Under the best treat- 
ment, the disease will return with each pair of teeth ; and not only 
does it trouble children when getting their milk-teeth, but also occa- 
sionally when cutting the permanent ones. In many of the cases 
which occur after eruptive and other fevers, the state of the tongue, 
the thirst, the appearance of the secretions, and the tumefaction and 
tenderness of the abdomen, evince that there is considerable irrita- 
tion or inflammation of the mucous membrane of the stomach and 
bowels. In such circumstances, the patient may be placed under the 
following treatment: — Gentle aromatic laxatives, repeated accord- 
ing to the state of the bowels; a diet consisting of bread and milk, 
arrow-root, sago, whey, &c; the application of leeches to the abdo- 
men ;— the tepid bath ; and sometimes an eruption of pustules may 
be produced upon the belly by means of antimonial ointment. 

Mr. Plumbe states, at page 121 of his excellent work on "Dis- 
eases of the Skin," that, in much neglected cases, a perfect cure has 
seldom been produced, except when "the operation of plucking the 
hair from the diseased part has been diligently followed up, and every 
other possible means taken to check inflammatory action." I must 
confess that such cases are very rare in this country, so much so, 
that in my dispensary practice for many years, the patients averaging 
about four thousand annually, no such intractable instances have 
occurred, notwithstanding the reputation for dirtiness which the 
Scotch have acquired in the minds of their English neighbours! 

Appearances of the most severe forms ofporrigo. — The following 
description of the disease is compiled from the work of Mr. Plumbe, 
who has devoted much time and attention to affections of the skin, 
and more particularly to this disease. 

"The degree of obstinacy evinced by a larger portion of cases of 
this disease, the interruption it frequently occasions to the education 
of children, (its known infectious nature preventing their admission 
into schools,) combine with other circumstances to give it a peculiar 
interest." Mr. Plumbe thinks that there are two particular forms of 
the disease which produce all the varieties mentioned by authors, and 
that both occasionally arise spontaneously, or are the result of infec- 
tion, and that the one may produce the other. 

In the first form, the hair falls orF, leaving sometimes, but not al- 
ways, circular patches, the margin being clearly defined, and ex- 
hibiting a line of scurf considerably thicker than that in the centre. 
In the centre of the spots, the skin is scurfy, and the hair thinned, 
and easily extracted by the finger and thumb. What remains of it 



PUSTULAR DISEASES. 679 

is unhealthy in appearance, some hairs being thin and delicate, others 
being the remains or stumps of those which have been broken, or 
dropped off. There is a downy substance just rising above, and 
mixing with the scurf, evidently formed by feeble attempts at the 
production of new hair. The spots vary in number and in dimen- 
sions, and on the hair being removed, exhibit a red and slightly in- 
flamed appearance. Here and there this form of the disease will be 
observed in an incipient state, and is known by small discolorations 
of a yellowish red colour before the hair begins to drop off. The 
spots show no pustular appearance at the margins, and enlarge 
slowly in diameter till they unite; but if stimuli, in the form of oint- 
ments, have been applied, a more active condition often takes place, 
and minute achores form not only on the margins, but on other parts, 
accompanied by irritation, heat and itching. The pustules discharge 
their conienis, and form scabs of a light straw colour, under which 
extensive abrasions of the etuis are sometimes found. 

S|mis of the same nature may be seen on different parts of the 
body, at (lie commencement of the affection of the scalp, and for some 
time after, but they generally disappear before its termination. 

This is the usual appearance of the disease in children, whose 
general health is unimpaired, and skin not particularly irritable; but 
in opposite conditions, small pustules,instead of vesicles, are perceived, 
which dry and form a circular scab. The ring of pustules enlarging 
in the same manner as that of the vesicles, and their contents drying, 
and adhering to the margin of the scab already formed, increase its 
bulk and diameter. The scab becomes a source of increased irrita- 
tion, and the pustules under its margin are enlarged and more ele- 
vated, raising its edges, and giving the appearance of the P. lupinosa. 

The other variety of porrigo never assumes the circular, circum- 
scribed form of the one just described ; but is diffused over a con- 
siderable space, and is pustular from the beginning on the scalp. 
It can, like the other, be identified with an affection of the skin of 
other parts, which is partly vesicular, and partly consists of papulae 
of different rises. 

Tip- pustules are thickly dispersed over the head. and a hair occu- 
pies ihe centre of each, iiie skin in ihe interstices being red and in- 
ilatned. Tins form of ihe disease is accompanied by fever and 

irritation ; and derangement of the digestive organs will be found to 
have existed, generally, for a long time previous. The absorbent 
glands at the hack of the head and those of the neck intlame, and 

sometimes, though rarely, suppurate. Inflammation of the cellular 
membrane, under the scalp, takes place here and there, forming ab- 
scesses which burst and soon heal, hut leave the parts which they 
occupy bald ever after. 

As the pustules are ruptured, and their contents distributed over 
the adjacent parts of the scalp, these parts become inoculated, the 
disease spreaas, and yellowish scabs are Conned of an unpleasant 

odour and aspect, which, unless frequent ablution be had recourse to. 
Vapidly accumulate. 

These descriptions! according to Mr. PJumbe, comprehend every 

thing essential to the history of porrigo, (except as regards the P. 



680 PUSTULAR DISEASES. 

favosa and P. larvalis,) as it occurs in the better classes of society, 
where cleanliness is particularly attended to, the general health not 
materially injured, and where the disease is not aggravated and its 
character changed by the improper use of stimulant applications; 
and, under these circumstances, both will frequently disappear spon- 
taneously by the continued employment of ablution. But, under 
other circumstances, both forms may terminate in that most obstinate 
and intractable one— the P. furfurans of JBateman, which seems to 
be the result of long-continued irritation. Its principal distinguished 
feature is the copious production and rapid exfoliation of morbid 
cuticle, which, from its branny form, is readily entangled by the ad- 
hesive matter of the pustules forming a sort of cement. The union 
of the morbid cuticle, which is secreted in great quantities, with the 
matter of the pustules, increases the mischief by matting the hair 
together, and preventing the application of remedies. Upon examina- 
tion in this state, after cleaning the scalp by the long-continued use 
of warm water, the interstices of the hair exhibit an erythematous 
redness, and appear altogether deprived of cuticle; the passages by 
which the hairs arrive at the surface are enlarged, the covering which 
they receive from the cuticle is destroyed, and its place occupied by 
a glutinous fluid, which may be seen exuding, and surrounding each 
individual hair. The quantity of this secretion varies at different 
times, and the proportion which it bears to that of the exfoliations of 
the cuticle, determines the consistence and adhesiveness of the dis- 
eased part ; and hence, when small in quantity, the latter is more 
dry, harsh and shining. 

In this state of the disease, and also under all other circumstances, 
when the accumulated secretions are considerable in quantity, the 
term "scalded head" is generally applied. 

Treatment of the most severe forms of porrigo. — Cleanliness, 
and preventing the formation of hard scabs, are of still more im- 
portance in the cases now under consideration than in those of a 
milder character; and when scales have formed, they are to be soft- 
ened by means of fomentations and a poultice of linseed meal. Gen- 
tle mercurial laxatives are also serviceable, assisted by the daily 
use of Harrogate water. The diet must depend entirely upon the 
state of the constitution, as to whether it ought to be very nourishing 
and somewhat stimulating, or the reverse; but in all cases the sto- 
mach must not be overloaded, and the diet should be dry. The use 
of the tepid bath will be found very advantageous. 

It would be impossible to give an account of all the local reme- 
dies which have been used for the cure of porrigo; therefore 1 shall 
merely enumerate some of them. Coarse soft soap, sulphur oint- 
ment, or both conjoined; ointment of the cocculus indicus — of the 
oxide of zinc — of calomel — of the red oxide of mercury — of nitrate 
of mercury — of tar— of nitrous acid — muriate of ammonia — of ace- 
tate of lead and opium — hellebore — turpentine — mustard — stavesacre 
— dulcamara — black pepper — cayenne pepper — galls — savine, &c. 
Lotions of acetate of lead, sulphates of zinc and copper, infusions of 
tobacco and tar-water ; equal parts of the spirits of wine and oil ; 
and also the same proportions of vinegar and oil, muriate of mer- 



PUSTULAR DISEASES. 681 

cury, in alcohol, in water and lime water; the black wash, a solution 
of nitrate of silver, and tincture of the muriate of iron ; blisters. 
Some recommend the part to be powdered with sulphur; the direct 
application of a stick of lunar caustic; adhesive plaster; the oil-silk 
cap, and pitch cap. 

In addition to the constitutional remedies for the cure of the true 
vesicular circumscribed ring- worm of the scalp, I find few cases 
resist the nitrate of silver, applied by rubbing it carefully over all 
the diseased parts, and re-applied as soon as the dark-coloured exfo- 
liation separates. 

In the other form of the disease, the formation of scabs will be 
prevented, at least in a considerable degree, by wearing a wax-cloth 
or an oil-skin cap; when this is done, however, the patient should 
have two or three changes of caps for the sake of cleanliness, and to 
avoid an almost insufferable smell. Mr. Plumbe has been very 
successful, by removing the roots of the hair with a pair of pincers, 
which is a merciful alternative for the old pitch cap ; and should any 
local inflammation be excited, he recommends the use of a cooling 
lotion. 

SCABIES OR ITCH. 

This disease, as Bateman admits, almost bids defiance to any 
attempt to reduce it to an artificial classification, as it appears some- 
times in the form of pustules, vesicles and papulae, the one variety 
often running into the other. In all of these forms it is accompanied 
by a constant and almost irresistible itching. It is contagions, but 
is not attended with fever; all parts of the body are liable to it, ex- 
cept, perhaps, the head, particularly the wrists, between the fingers, 
the flexions of the joints, &c. 

Causes of scabies. — It has been universally attributed to contagion, 
but it appears to me that this cause has its limits, and that it depends 
as much) if not more, upon a state of the constitution the consequence 
of diet. It seems to 1m: almost endemic in some remote districts of 
this country, in Ireland and in France, where sulphur, the sovereign 
remedy, baa no effect in exterminating it, because it is an eruption 
produced by unwholesome food. In the army it is rare to Bee an 
old soldier affected with itch; the subjects mostly affected are re- 
cruits, recently joined, who had either brought the disease into hia 
majesty's service with them, or had caught it from other recruits. 
they themselves being predisposed to it by a change of diet and 
habits. 

[It seems now to be established beyond contradiction, that the itch 
is accompanied by ao insect. This has long been the popular opin- 
ion, and lias also been maintained by many medical authors, and 
Dcgerr gave tO the supposed insect the nam" pf .Icarus sra/u'ei. 
Th<: absolute discovery is due to M. Rcuueei, who, by experiments 

at the Hospital St. Loms at Paris, succeeded in obtaining great num- 
bers of acari, which WOW at once lufomitfed to inspection by means 
of a microscope. \» to us existence no doubt whatever remains j 
but an intelligent writer has inquired whether it is the cause of the 

57- 



682 PUSTULAR DISEASES. 

vesicle, and if so, how? "Is the vesicle caused by the deposition of 
the eggs, the development of which determines inflammation — or by 
the deposit of a poison by irritation produced by its members, or by 
its bite? Or does it show itself in the individual merely in conse- 
quence of the attraction produced by the itch matter, or the filth 
attached to the person ?" Leaving these points to be decided by 
future investigation, we shall merely add a description of the insects 
by M. Raspail:* 

" The Jlcarus scabiei seen through the microscope, presents the 
form of a tortoise; a shining surface, more transparent in the centre 
than at the circumference, of a white opaque colour. Its other 
shades would appear to be the result of the divison of luminous rays 
passing through the lens. The head, which may be considered a 
perfect retracting sucker, is provided at each side with two articulated 
feet, terminating at the tarsus in a funnel-shaped prolongation. The 
insect is armed with four additional feet, longer than the former, but 
without the funnel-shaped appendage : this articulation is not at the 
sides like those of the horse-acarus, but underneath the belly : on the 
back is perceived a number of eccentric lines at short intervals, and 
having the appearance of joints. The belly presents several dark- 
coloured spots: the body and legs seem furnished with a quantity of 
hair of unequal length."] 

Treatment of scabies.— This is so well known, that medical men 
are rarely applied to. The specific powers of sulphur, applied ex- 
ternally in the form of ointment, and taken internally in half-drachm 
doses with an equal weight of cream of tartar, soon cure the affec- 
tion. Three or four days are generally sufficient. Other remedies 
have also been extolled, as the root of white hellebore, diluted sul- 
phuric acid, and the muriate of mercury, all of which have been 
used with benefit. In obstinate cases, Dr. Robertson has seen much 
benefit arise from mixing half an ounce of powder of white helle- 
bore with four ounces of sulphuric ointment. 



ECTHYMA AND RUPIA. 

Perfectly agreeing with Mr. Plumbe,that these are merely vari- 
eties of the same disease, I have thought it right to consider them 
together, particularly as they occur under the same states of constitu- 
tion, and are to be treated in the same manner. Indeed, Bateman 
observes, when treating of rupia, (at p. 237 :) " For practical pur- 
poses it might have been included with the ecthymata, as it occurs 
under similar circumstances with the ecthyma luridum ; but the 
different form of the eruption, for the sake of consistency of lan- 
guage, rendered the separation necessary." According to Bateman, 
we have five species of ecthyma, and three of rupia, the one differing 
from the other only as to the age of the patient, and the colour and 
form which the eruption takes. Ecthyma and rupia may be defined 
to consist of an eruption of inflamed pustules, commonly of a large 

[* A full account of this discover}', with an admirable engraving of the insect, is 
contained in the American Journal of the Medical Sciences for February, 1835.] 



PUSTULAR DISEASES. 683 

size, raised on a hard circular base, of a vivid red colour, and suc- 
ceeded by a thick, hard, dark-coloured scab, usually distinct, and 
arising at a distance from each other. This kind of eruption is indi- 
cative of some state of distress under which the constitution labours, 
and though it is not attended with actual fever, yet a degree of 
general irritation or erythism is often present with it. Occasionally 
the eruption is confined to the trunk, but sometimes spreads to other 
parts, seldom, however, being seen on the face or hands. 

Causes of ecthyma and rupia. — According to Mr. Plumbe, "Anx- 
iety of mind, accompanied by great bodily exertion, fatigue, low 
living, the debilitating effects of previous fever; in short, any thing 
reducing the energies of the constitution beyond a certain extent, is 
capable of producing it. Almost the whole of the cases which I 
have had an opportunity of observing, have occurred in young 
people ; the majority in young men, who, with constitutions originally 
not of the strongest class, had imprudently indulged in excesses and 
irregularities to a great extent, accompanied by privation of rest and 
other depressing circumstances. Very frequently, in such cases, it 
is mistaken for a venereal eruption, and the patient himself is readily 
made to believe in an opinion which his habits have made so pro- 
bable. If mercury be had recourse to under these circumstances, 
the disease is much aggravated," &c. 

Pathology.— From a careful consideration of all the cases of this 
kind of disease which have fallen under my notice, as well as from 
what I have read, I cannot help regarding the pustules above de- 
scribed as efforts of nature to translate disease to the surface; that 
they depend upon irritation, and the remains of inflammation in the 
mucous membranes generally; and that they are not produced by 
mere debility of constitution, as is generally supposed. 

Treatment of ecthyma and rupia. — According to the above 
views the treatment is simple, and consists in the daily use of the 
tepid bath ; mild laxatives, occasionally combined with a mercurial 
preparation ; light nourishing diet, avoiding beef tea, and all other 
forms of animal food, till the tongue improves in appearance, and 
the stools look more natural. In the course of some days the sul- 
phate of quinine will be found very serviceable; but it is not to be 
employed until the tongue becomes quite clean. On some occasions 
I have seen benefit derived from a blister applied on the lower part 
of the chest, more particularly when the sound of respiration an- 
nounced the presence of a bronchilic affection. 

A few years ago a gentleman was under my care with the worst 
form of rupia I had ever seen; every part of the surface of the body 
was affected. He went to London lor advice, and consulted several 
eminent medical gentlemen. Every one condemned the employ- 
ment of mercury in any form. I was decidedly opposed to it. Ho 

remained in a bad stale for two years, when he was seized with 
iritis in a severe manner. Dr. Robertson was then consulted, who 
placed him under an immediate course of mercury, to affect the 

system rapidly. As soon as the mouth began to show the usual 
effect of mercurial action, the disease of the skin began to decline, as 
well as that of the eye, and the patient was soon cured. 



684 PUSTULAR DISEASES. 



Bateman has divided this simple disease into four varieties, viz.: 
acne simplex, punctata, indurata and rosacea, thus creating distinc- 
tions without differences, the only effect of which is to embarrass 
students. This affection has also obtained the name of slow suppu- 
rating tubercles; and it appears to me that the reason why it is called 
a tubercle, and classed as such in all the books on cutaneous diseases, 
except Mr. Plumbe's, is that a hard, painful, circumscribed body is 
felt under the skin, which is perceived for a considerable period, 
now and then becoming painful, and continuing in this state for 
many months, and at last suppurating, perhaps only from having 
been frequently irritated. 

There cannot be the least doubt that the pathological views of Mr. 
Plumbe concerning acne are quite correct. They accord with the 
opinions upon which I have acted for a number of* years, viz.: that 
acne is a diseased condition of the sebaceous follicles. In the slighter 
cases the sebaceous matter concretes, distends the follicle, irritates it, 
and produces inflammation; slight suppuration takes place, a pimple 
is formed, and sebaceous matter is discharged, with or without a 
small quantity of pus. In the severer cases a higher degree of in- 
flammation is produced, involving the surrounding cutis; the sup- 
puration is more extensive, and slower in its progress, and perhaps 
the part suppurates again and again until the follicle is emptied, or 
its structure is completely destroyed. 

The parts chiefly affected are the forehead, the sides of the nose 
and the shoulders. The age at which acne most frequently occurs 
is that of puberty, alike affecting males and females. 

Causes of acne. — Although acne be not preceded by fever, and 
notwithstanding that it seems to be produced by the sebaceous matter, 
yet it is not difficult to show that it is connected with the state of the 
constitution, not only from the age at which it occurs, and the bad 
habits of drinking and gormandizing which frequently induce it, but 
also from the state of the tongue and the digestive organs. It occurs, 
likewise, under diseased states of menstruation, and under sedentary 
habits. 

Treatment of acne. — This may be divided, as in other cases of 
skin diseases, into constitutional and local. The first consists in 
attention to the bowels and diet, and taking all the ordinary means 
to improve the powers of digestion, including the warm bath. The 
local treatment consists in avoiding stimulating applications during 
the inflammatory stage, and puncturing the part to prevent sup- 
puration and allow a free passage to the sebaceous matter, without 
injuring or destroying the follicular structure. This has the effect, 
also, of preventing any permanent hardness, which so frequently 
happens when the process of suppuration is very slow, or when it 
does not take place at all. If matter have formed, the lancet should 
be used to allow its escape, and gentle pressure applied at the same 
time to force out the hard sebaceous matter. I know many females 



PUSTULAR DISEASES. 685 

who bear marks from the disease, before the plan of early puncturing 
the pimples was adopted. Individuals liable to this affection should 
pay scrupulous attention to diet and to the state of the bowels; they 
should employ friction with a flesh-brush, a piece of flannel, or a 
soft towel, and use the warm bath twice or thrice a week, and daily 
ablution. 



This affection scarcely deserves a separate consideration from 
acne. I agree with Mr. Plumbe that it is produced by follicular ob- 
struction, and consequent inflammation occurring in parts covered 
with hair; and its principal seats are the chin in men, and the head 
in both sexes, particularly the margin of the hairy scalp, in the 
occiput, around the forehead and temples, and near the external ear, 
which is also liable to be included in the disease. Sycosis is more 
troublesome than acne, as are all eruptive diseases situated on parts 
covered with hair. 

Treatment of sycosis. — The constitutional and local treatment 
recommended in acne must be followed up, with this addition in 
severe cases, that not only is the point of the lancet necessary, but 
the forceps also, to extract any hair which may appear to be a source 
of irritation ; and it is particularly necessary on the chin, where, on 
many occasions, the root of the hair itself will be found in a diseased 
thickened state. The extraction is seldom attended with any pain. 



CHAPTER V. 
SQUAMOUS DISEASES. 



Under this designation I shall consider the following diseases: — 
Lepra, Psoriasis and Pityriasis, which latter I might, perhaps, with- 
out any disadvantage, altogether pass over, because I consider it as 
the mildest form of lepra. I have not included ichthyosis, or fish- 
skin disease, because it is exceedingly rare ; it has the same patho- 
logy as lepra, and similar treatment is applicable to this affection. 
One form of it, ichthyosis cornea, is a surgical disease. 



By this term is designated a disease exhibiting red, inflamed, ele- 
vated spots and patches, in many cases not larger than a split pea, 
which yields almost daily crops of scurf or scales, and is rarely, if 
ever, accompanied by a vesicular or pustular appearance, unless such 
formation be accidentally produced by roughly tearing out hairs. After 
seeing the disease once, the scales can never be mistaken for scabs 
formed by the drying of pustules or vesicles, unless the affection have 
run into the state called psoriasis, which falls next to be described. 
Willan and Bateman have divided the disease into three species, 
lepra vulgaris — alphoides — and nigricans. The first two ought to 
be regarded as different degrees, or perhaps rather stages, of the same 
affection ; while the last species, nigricans, differs in the colour and 
state of the constitution at the time; and I heartily agree in the fol- 
lowing remarks of Mr. Plumbe: "That they may be dispensed with, 
with advantage, is obvious, inasmuch as they have had their share 
in creating the confusion elsewhere alluded to, and discouraging the 
student in the prosecution of his inquiries. It is to little purpose that 
preceding authors have expended so much time in investigating the 
confused records of ancient times, to determine what was meant by 
the term, and to ascertain the correct history of the disease, if new 
difficulties in its study are to be invented by encumbering it with 
useless and multiplied names" — (page 12S.) On looking minutely at 
the part affected, it is observed to have a shining hard surface, owing 
to a somewhat transparent, smooth, polished scale, which separates 
in a day or two, and to be encircled by a dry, red and slightly ele- 
vated border. When the scales are removed, the skin underneath 
appears smooth, red and shining, and generally free from cuticular 



LEPRA. 687 

lines. As the diseased spots extend, fresh scales are produced, having 
a somewhat different appearance from those formed at the beginning 
of the disease; they do not extend uniformly over the diseased sur- 
face in one continued scale, but separate more like scurf. The dis- 
ease very generally commences on the extremities, at parts where 
the bones lie nearest the surface, but I have often observed the erup- 
tion appear first on the surface of the abdomen, breast and shoulders. 
The head, face and hands often become involved in the disease, and 
in very severe cases, the nails of the fingers and toes are much 
thickened, incurvated at the extremities and sometimes fall off. When 
the disease covers a considerable portion of the body, a large quantity 
of scurf is found in the bed in the morning, which is rapidly repro- 
duced. 

More or less of an itching or a tingling sensation is experienced by 
the patient when heated by exercise, or in bed ; but when the disease 
becomes extensive, with considerable inflammation, extreme soreness, 
stiffness, and sometimes severe pain are produced, more particularly 
at the flexures of the joints, where the skin often cracks, discharges 
serum, and, in fact, runs into the state termed psoriasis. The parts 
likewise swell so much in these circumstances, that I have seen a 
limb fully more than a third above its natural circumference. 

It is surprising to find Bateman stating, at page 2S. that, in the 
worst of these circumstances. " there is no constitutional disturbance." 
If by this expression he means to say that there is no fever, the state- 
ment is correct; but there is frequently considerable and severe con- 
stitutional disturbance without the existence of febrile symptoms; 
and when speaking of the causes of this disease, I shall endeavour to 
describe the actual constitutional derangements upon which the dis- 
ease appears to depend. 

Causes of lepra. — Leprous disorders are very often met with 
among the poor in all countries, but they are more frequent and 
severe in warm climates, and in countries where the poor are most 
destitute. I do not believe that they originate in want ol cleanliness, 
but certainly, when once produced, it renders them more intractable. 
All causes which hive ;i tendency to produce functional diseases of 
the chylopoietic viscera may be ranked as causes of lepra in pellicu- 
lar constitutions. Sometimes, tnd most frequently, it is produced by 
unwholesome and indigestible food, particularly such articles as yield 
little nourishment. Affections of the mind may likewise give rise to 
it. The rich are not exempt from this disease, and it frequently at- 
tacks those with gouty constitutions, For many years past, 1 havo 
paid considerable attention lo disorders of the skin, and a great many 
cases of lepra ami psoriasis have fallen under my observation ; gastro- 
intestinal irritation has been discovered m all the cases hut one; and 
in that one, there, were great mental anxiety and despondency, with 
hepatic derangement. There ean be no doubt thai the disease, m 
the lirst instance, is sealed in the vessels of the cutis winch sre em- 
ployed in producing the cuticle, and that its nature is inflammatory. 
Treatment of lepra*— In detailing the treatment, | shah describe 
the different plans which experience and pathological considerations 



688 SQUAMOUS DISEASES. 

have led me to follow with great success, and I shall notice these 
under different heads. 

1. In all cases, it is necessary to attend to the bowels by gentle, 
but frequently repeated laxatives, occasionally combined with calo- 
mel, and assisted also by the daily use of Harrogate water. The 
diet must likewise, in all cases, be attended to ; and it will be found 
that the disease often depends upon one particular article of diet, 
varying in different constitutions, as dried-fish, shell-fish, salted 
meats, new bread, coarse and unwholesome bread, potatoes, onions, 
garlic, salads, cheese, oat-meal, sweetmeats, bitter almonds, nuts, va- 
rious kinds of fruits, particularly if the skins or husks be swallowed, 
broths and soups, different kinds of malt liquors, cider, wine, spirits, 
&c. Indeed, the diet is of such vital consequence, that I consider it 
necessary, in many obstinate cases, to make my patient write down 
a daily list of every article which he has put into his stomach, so that, 
by comparing his condition with the food he has been using, we are, 
between us, able at last to detect those articles which disagree. It 
is also necessary to take care, that while the patient has sufficient 
clothing, his skin is not kept too hot; and I have sometimes found it 
of service to cause linen to be worn next the skin instead of flannel. 
When it can be managed, the inner garments should be changed 
daily, particularly in severe cases; and this is still more necessary 
when the disease takes on the appearance which constitutes psoriasis. 
When the patient goes to -bed, care should be taken that his feet be 
warm, and that he be not over-heated by too many bed-clothes. The 
tepid bath should be used daily, or when that is inconvenient, the 
whole body should be sponged twice a-day with soap and warm 
water, or vinegar and water. 

2. If the inflammation of the skin be very severe and extensive, 
I commence by taking blood from a vein in such quantity as may be 
necessary, attending to the state of the constitution as well as the 
extent of the inflammation, and afterwards proceed with the plan 
above described ; and there are few cases which resist these means. 

3. In old or very intractable cases, where these remedial means 
have been tried without success, recourse should be had to sulphure- 
ous baths and fumigations, which can scarcely be praised too highly; 
but they must not be used when the inflammation is acute. When 
these cannot be obtained, some benefit may be derived from the 
external application of Harrogate water, several times a-day. 

4. Instill more intractable cases, where the above remedies have 
failed, or where sulphur baths cannot be obtained, considerable bene- 
fit will be derived from the use of lime-juice, externally as well as 
internally; but I place more dependence on the employment of an 
alcoholic solution of the oxymuriate of mercury, in the proportion 
of four grains to the ounce, beginning with from five to ten drops 
twice or thrice a-day, and increasing each dose to twenty, thirty or 
forty drops, of course attending at the same time to the diet, bowels 
and clothing. 

5. Should these plans fail, recourse is to be had to arsenic, which 
is placed last in the list of remedies, because its use is frequently at- 
tended by more constitutional disturbance. But I have seen it fail 



PSORIASIS. 689 

in cases where the other plans have afterwards succeeded. For 
some years past I have only had occasion to employ it twice, on 
both occasions without success: in one instance it was persevered in 
till the patient was nearly poisoned. Maddaror madaar, an Indian 
remedy, was also tried in this case, but only with temporary bene- 
fit. Various ointments, such as that of tar, nitrate of mercury, and 
carron oil, have been employed, but, according to my experience, not 
with much success. 

A most injurious plan is followed by some, of putting all patients 
affected with lepra, and other skin diseases, on farinaceous food, with 
which they stuff themselves in such a manner as to increase the 
functional derangement of the stomach and bowels, thereby pro- 
ducing a more inveterate affection. Many instances of this kind of 
maltreatment fall annually under my care, in which a change to ani- 
mal diet has generally effected a beneficial change in the character 
of the disease; an interesting case of this nature I shall soon notice, 
wheti treating of psoriasis. In addition to what has been said 
already respecting diet, it may be shortly remarked, that in cases 
where inflammation of the skin runs high, an abstemious diet should 
be recommended, but, generally speaking, a moderate quantity of 
animal food is necessary. In no case should the patient be allowed 
to loud the stomacb,and he should be cautioned particularly against 
taking more than a small teacupful of soup of any description; he 
must likewise altogether avoid taking that " animo-vegetable decoc- 
tion" called Scotch broth. The tongue should be frequently exa- 
mined as well as the stools, as from both of these we may draw con- 
clusions respecting the effects of diet and medicines. Tonics are 
often serviceable, as well as a moderate allowance of such stimuli as 
are found to agree best with the patient, and which he can afford. 



According to Bateman, " Psoriasis or scaly tetter occurs under a 
considerable variety of forms, exhibiting, in common with lepra, more 
or less roughness, and scaliness of the cuticle, with redness under- 
neath. It differs, however, from lepra in several respects. Some- 
times the eruption is diffuse and continuous, and sometimes in sepa- 
rate, patches of various sizes; but these are of an irregular figure, 
Without the elevated border, tin: inflamed margin, ami the oval or 
oirrular outline of the leprous patches: the surface under I fie scales 
is likewise much more tender and irritable, in general, than in lepra; 
and the skin is often divided by rhagades, or deep fissures." And 
he might have added, that when the inflammation runs high, and 
extends deep into the substance of the eutis, there is often a very 
considerable discharge from these fissures, and even from the gene- 
ral surlier, forming extensive scabs; but this, for me mosl part, 

never takes place except in mismanaged cases. I have seen the 
eruption leprous in one part of the limb, and psoriatic in another, 

particularly between the Angers, and at the flexures of the joints. 

Lepra may be converted into psoriasis by bad management, and 
58 



690 Squamous diseases. 

particularly by the application of irritating substances to the diseased 
parts. Psoriasis may be converted into lepra by a general bleeding, 
thereby mitigating the local inflammation. From all the facts which 
experience has enabled me to collect, psoriasis is to be regarded as 
an aggravated form of lepra, and by treating it upon corresponding 
principles, I have been very successful in curing the affection. 

Willan and Bateman have divided psoriasis into four varieties — 
viz.: the guttata — diffusa — gyrata and inveterata; but I shall 
avoid such distinctions, as no good practical results can be expected 
from them. 

This disease, like lepra, may be very partial ; but I have seen 
several cases where the whole of the extremities were covered with 
psoriasis, while the trunk of the body, the face and the head were 
affected with lepra. I shall now relate the case recently alluded to, 
(p. 689.)— A gentleman of a healthy, strong constitution, accustomed 
to good living, and engaged in an extensive speculation, experienced 
a great and an unexpected reverse of fortune." Possessed of highly 
honourable feelings, he was determined to pay off every shilling of 
debt, by reducing his establishment and altering his style of living, 
and, it is to be regretted, by denying himself many of the common 
necessaries of life. For upwards of two years he lived almost en- 
tirely upon fish and potatoes, and he employed himself so assiduously 
at his business, that he never went out to take exercise except when 
obliged. In the course of time, a leprous eruption appeared upon 
his arms and legs, but it gave him little trouble, and he did not apply 
for medical advice ; by and by it appeared here and there upon the 
trunk of the body, still it attracted little of his attention. One day- 
he slipped his foot and sprained his ankle, which swelled much, and 
was attended with pain. He sent for a doctor, who confined him 
to bed, leeched the part affected, put him upon the strictest anti- 
phlogistic regimen, and prescribed a dose of salts daily. Under this 
treatment the leprous eruption extended rapidly; his appetite be- 
came bad, the tongue foul and loaded. At the end of a month the 
surface of both extremities was inflamed, and the disease was now 
converted into psoriasis, with excessive discharge, swelling and itch- 
ing. All kinds of local applications were tried without benefit ; and 
when I was consulted, the gentleman was in the following condi- 
tion : — His legs and arms were much swollen, painful, and so itchy 
that he was deprived of rest; they were covered with scabs, which 
were produced by the partial drying of a profuse discharge of fetid 
serous fluid, which seemed to ooze from every pore of an intensely 
red, shining and highly inflamed cutis. So profuse was the dis- 
charge that it soiled the bedding, and notwithstanding every pre- 
caution, no means could be devised to prevent the linen from stick- 
ing to the affected parts, the separation of which produced great 
pain, aggravated the local inflammation, and frequently caused 
bleeding from the parts. The trunk of the body, the face and scalp 
were also affected with that form of lepra termed vulgaris. His 
strength was destroyed, partly by the remedies and the diet, and 
partly by the constitutional irritation and want of sleep, but prin- 
cipally by the constant profuse discharge. He had now been con- 



PITYRIASIS. 691 

fined, for the most part to bed, for about 140 days. The pulse was 
quick and weak ; he had constant singing in his ears, giddiness upon 
raising his head from the pillow ; and for some days he had always 
fainted upon getting up for necessary purposes. Notwithstanding 
the quantity of salts and other purgatives taken, his bowels were in 
bad order, the stools were scanty, very dark in colour, and fetid; 
the tongue was swollen, rough, fissured, and covered with a thick 
crust. The following treatment was adopted. The carron oil was 
changed for a warm solution of sugar-of-lead to the parts affected, 
which was applied by means of bandages kept wet with it: a few 
doses of calomel were exhibited ; and he was allowed some wine 
and water. From this time he enjoyed good rest ; the tongue im- 
proved so much in two or three days, that he was allowed a small 
quantity of animal food; the heat, inflammation and discharge were 
so much diminished in the course of three or four days, that the satur- 
nine lotion was discontinued, and the limbs were enveloped in fine 
oil-silk. He made such a rapid recovery, by the assistance of small 
doses of blue pill and Harrogate water, that he considered himself 
quite well in the course of three weeks; and although he has since 
had several slight relapses, they were attributed to errors of diet, 
and inattention to the bowels. Exactly a year afterwards, the dis- 
ease returned in a severe form on the extremities, but was speedily 
cured by one general bleeding and the employment of the local re- 
medies. Five years have now elapsed, and this gentleman is in the 
enjoyment of excellent health and has had no return of the complaint. 
Treatment of psoriasis. — The above case shows the treatment 
that I would recommend; and the only circumstances which ought 
to be mentioned in addition to what has been stated respecting lepra, 
are the greater necessity for cleanliness, and the application of oil- 
silk to the affected part. 



PITYRIASIS. 

Tin- is a very niperficial affection, consisting of irregular patches 
of slender scales-, which repeatedly exfoliate and recur, hut which 
neither form crusts nor are accompanied by fluid excretion or ex- 
coriations; and it is stated not to be contagious. The most frequent 
si r un tion of pityriasis is the scalp, and when it attacks infants, it is 
commonly called "dandriffj" Willan and Bate man have given it 
the term pityriasis capitis. It is now and then observed in adults, 
particularly those of dark complexion. Cleanliness, in this instance, 
prevents the disease from being troublesome; and n may be easily 
removed, even when the scurf is pretty thick, by washing the part 

with BOap and \vat--r, rind a soft hrush daily, or using a solution of 

the carb. soda When neglected, however, it runs into a state much 
ing the worst form i of porrigo. 
Pityriasis in a severe form now and then occurs in adults,* pro* 
ducing considerable discomfort to the individual. According to Mr. 
Plnmbe, different p iris of the body become the seats of much itching 
and tenderness; and when Diction is employed, scabs of considerable 



692 SQUAMOUS DISEASES. 

thickness fall off, the parts below exhibiting a red, shining, glossy, 
and someiitnes slightly moist surface. The skin of the chest and 
back are the common seats of this form of the affection; but the 
hairy scalp and its margin also partake of it. The colour of the 
parts, when covered with the diseased cuticle, is of a lightish yellow, 
or copper hue ; when the cuticle is removed, it approaches more to 
red ; but the cutis at no time appears of the colour consequent on 
common abrasion. The figure of the patches is very various ; "here 
and there are spots of from half an inch or less, to two or three 
inches in diameter, approaching, perhaps, to a circular form. These 
will, perhaps, be found around the margin of a larger patch, the out- 
lines of which are as irregular as the outlines of a map of an island. 
The colour of these larger patches also varies from time to time in 
different parts, from a light straw to a reddish colour; hence the 
terms Pityriasis versicolor, P. rubra, which Willan and Bateman 
have formed into varieties." 

Causes and treatment of pityriasis. — ! have seen a limited 
number of cases of this disease which required any treatment; and 
therefore I shall make free to quote the pathological and practical 
remarks of Mr. Plumbe. He says.the disease, as occurring in adults, 
pretty uniformly attacks individuals of delicate health, and dimi- 
nished energy of circulation. In such states of the system, the cuta- 
neous vessels partake of the general debility, and have the disadvan- 
tages of their locality, as furtherest from the centre of circulation; 
and being exposed, at the same time, to vicissitudes of temperature, 
they are incapable of the formation of sound cuticle, and produce 
instead the delicate and ill-formed substance described. "The state 
of the circulation and system, in all cases which come under our 
notice, proves this view of the case to be correct. I have never seen 
a single case, (says he,) where want of energy was not apparent, 
and very few where the supply of this was not followed by speedy 
recovery. Violent and distressing impressions on the mind; original 
debility of constitution, the depressing effects of long-continued 
illness in warm climates, &c, are found very commonly to have 
been co-existent with the first appearance of the disease." 

The constitutional treatment which will be found most successful, 
is that which is in strict accordance with the above principles. Mea- 
sures which tend to invigorate the system, will be always proper if 
not forbidden by organic disease. Bark, steel, sea-bathing, gentle 
exercise in the open air, ease of mind, nourishing food, and plenty of 
rest, constitute what is usually requisite on such occasions. Now 
and then the sulphur vapour bath has been rendered necessary, the 
cutaneous vessels having failed to recover their tone, though the 
general health had been much improved. When the scalp is much 
affected, and the scurf forms in considerable quantities, the free use 
of a solution of acetate of zinc, in equal parts of rose water and 
proof spirits, constitutes an agreeable and useful application. In 
addition to these remarks, it may be mentioned, that in the few cases 
which have fallen under my notice, the internal and external use of 
fresh lime-juice has been found beneficial, or common vinegar ap- 
plied to the diseased surface. 



CHAPTER VI. 
VESICULAR DISEASES. 



The following is Bateman's definition of vesicle: "A small orbi- 
cular elevation of the cuticle, containing lymph which is sometimes 
clear and colourless, but often opaque and whitish, or pearl-coloured. 
It is succeeded either by scurf or by a laminated scab." This author 
has divided his order vesiculae into seven genera, viz.: varicella, 
vaccinea, herpes, rupia, miliaria, eczema, aphtha. Each of these he 
has subdivided into several varieties. Some of his orders, as vari- 
cella, vaccinea, miliaria and aphtha, are misplaced; I shall conclude 
all that I have to say on vesicular diseases under the term herpes. 



Willan and Bateman have subdivided herpes into six species, 
viz.: herpes phlyctcznodes — zoster — circinatus — labialis — prxpu- 
tinlis—iris. According to the latter of these authors, this appella- 
tion is "limited to a vesicular disease, which, in most of its forms, 
passes through a regular course of increase, maturation and decline, 
and terminates in about ten, twelve or fourteen days. The vesi- 
cles arise in distinct but irregular clusters, which commonly appear in 
quick succession : and they are set near together, upon an inflamed 
hich extends a little beyond the margin of each cluster. The 
eruption is preceded, when it is extensive, by considerable constitu- 
tional disorder, and is accompanied by a sensation of heat and ting- 
ling, sometimes by severe deep-seated pain in the parts allected. 
'l'h'' lymph of the vesicles, which is at first clear and colourless, be- 
eoines gradually milky and opaque, and ultimately concretes into 
scabs; but, m some cases, a copious discharge takes place, ami tedi- 
ous ulcerations ensue. The disorder is not contagious in any of its 
forms." 

Herpetic eruptions occur in various parts of the body. When on 
the iipa ami angles of the month, the disease is called herpes labialis 

— when in the form of a hell acrOSfl the shoulder, or round the waist 

like a sash, it is termed herpes zoster, ami, in common language, 
"shingles." When il has no certain seat, but sometimes appears 

on one part of the body, sometimes mi another, with the exception 
of the situations already mentioned, the disease is termed herpes 

58* 



694 VESICULAR DISEASES. 

phlyct oenodes; but surely difference of locality is no reason why 
different appellations should be applied. 

This class of disorders is, for the most part, if not always, accom- 
panied by constitutional disorder, sufficiently marked to attract atten- 
tion, such as that produced by subacute inflammation of the bronchial 
membrane. Hence, we find it taking place towards the termination 
of what are called catarrhal fevers, producing immediate constitu- 
tional relief, which the strongest remedial agents had, perhaps, failed 
to accomplish. I have also often seen the other forms of the affec- 
tion, particularly that described as herpes zoster, occur in the course 
of bronchial inflammation; but more particularly when there were 
strong marks indicating a disordered state of the stomach and bowels. 

Females appear to be more subject to this disease than males, and 
people who are delicate, more than the strong and athletic. 

Causes of herpes. — Besides occurring under the forms of internal 
disease already mentioned, it has been referred to the suppression of 
hemorrhoidal or menstrual discharges, sudden change of habits as 
to diet, but more particularly from an active to a sedentary life. It 
may be produced by particular articles of food. 

With respect to the pathology of the herpetic eruption, its seat is 
in the superficial vessels of the skin, and its nature is inflammatory, 
the effect of which is effusion of serum, separating the cuticle by 
mechanical distension ; we see similar effects produced by blisters 
and some other external irritants. 

Treatment of herpes. — This is very simple, and consists in reliev- 
ing internal disorder and subduing any constitutional disturbances 
that may exist. The lancet is not often required, but I have seen it 
sometimes necessary and very beneficial ; in general, 'however, low 
diet, consisting of arrow-root and the like; gentle laxatives, repeated 
twice or thrice in the twenty-four hours; the warm bath and con- 
finement to the house, wiil be advisable. The best local treatment 
is to open each vesicle early, and occasionally to apply fomentations. 
But, in the most severe form of the complaint, viz.: the herpes zoster, 
where the pain is very severe, the best effects will be produced by 
applying a dozen of leeches on the inflamed part ; if done early, 
before many vesicles have appeared, the further progress of the dis- 
ease will be stopped. I observe that Mr. Plumbe has, in two or 
three instances, applied small blisters to the uninflamed skin in the 
neighbourhood of the vesicles, not only with the effect of checking 
their extension, but producing a shriveling of those already formed. 
If it be not found necessary either to apply leeches or a blister, the 
best application, after opening the vesicles, is a poultice of linseed 
meal ; and I can see no objections to the occasional application of a 
cooling saturnine wash. 

When treating of syphilis, I shall speak of an herpetic eruption 
affecting the prepuce, which is consequently termed herpes proepu- 
tialis. 



POMPHOLYX. 695 



PEMPHIGUS AND POMPHOLYX. 



There can be no doubt but that the diseases described under these 
two names have, in all ages, been confounded iwith each other. 
The terms denote the existence of large vesicles, which are termed 
" bullae," and, in common language, " blebs." The affection is called 
pemphigus when the blebs are preceded or accompanied by fever, 
and pompholyx when without fever and when the eruption is with- 
out an inflammatory base. The existence of pemphigus as a distinct 
disease was denied by Cullen and others, but it has been described 
by many authors. I have frequently seen large bullae take place in 
the course of slight as well as severe fevers; but, instead of consi- 
dering them entitled to any specific character, I have always looked 
upon their occurrence as an accidental circumstance, and have made 
no difference in the treatment of the original disease. With respect 
to local treatment, I have only to observe that the bullae are not to be 
interfered with unless there be considerable local irritation and pain, 
when a small puncture may be made with a lancet, and perhaps a 
light poultice of linseed meal applied ; but it is rarely necessary to 
interfere with them, unless, from the restlessness of the patient, they 
are ruptured, when the same application may be made to them. 

Pompholyx. — As far as I can understand, this disease, as defined 
by Willan and Bateman, is of very rare occurrence ; one case only 
has been seen in this city. It is in the person of a poor man, who 
appears to have no constitutional distress, and who is able to work 
hard for his daily support. 



CHAPTER VII. 
PURPURA. 



I purpose to treat, in this chapter, of that kind of purpura which 
is commonly known by the term purpura hemorrhagica. 

A number of diseases which appear on the surface of the body 
have been already described. Some of them terminate by suppu- 
ration, others by a secretion of serum ; a third class by the formation 
of scales, &c; and now we have to consider an affection where blood 
is poured out under the cuticle, forming appearances which are 
termed petechia, and upon the surfaces of all the cavities lined by 
mucous and serous membranes, forming dark-coloured spots, resem- 
bling, in every respect, those found on the cutis. Purpura is a dis- 
ease which is accompanied by such threatening symptoms, that it 
has riveted the attention of almost every medical man who has seen 
it ; but we are still in total ignorance of the pathology of the disease. 
The following description of purpura hemorrhagica is taken from 
Bateman :— " The petechias are often of a large size, and are inter- 
spersed with vibices and ecchymoses, or livid stripes and patches, 
resembling the marks left by the strokes of a whip, or by violent 
bruises. They commonly appear first on the legs, and at uncertain 
periods afterwards, on the thighs, arms and trunk of the body; the 
hands being more rarely spotted with them, and the face generally 
free. They are usually of a bright red colour when they first appear, 
but soon become purple or livid; and when about to disappear, they 
change to a brown or yellowish hue ; so that, as new eruptions arise, 
and the absorption of the old ones slowly proceeds, this variety of 
colour is commonly seen in the different spots at the same time. The 
cuticle over them appears smooth and shining, but it is not sensibly 
elevated ; in a few cases, however, the cuticle has been seen raised 
into a sort of vesicles, containing black blood. This more frequently 
happens in the spots which appear in the tongue, gums, palate and 
inside of the cheeks and lips, when the cuticle is extremely thin and 
breaks from the slightest force, discharging the effused blood. The 
gentlest pressure on the skin, even such as is applied in feeling the 
pulse, will often produce a purple blotch, like that which is left after 
a severe bruise. 

" The same state of the habit which gives rise to these effusions 
under the cuticle, produces likewise copious discharges of blood, 
especially from the internal parts, which are defended by more deli- 
cate coverings. These haemorrhages are often very profuse, and 



PURPURA. 697 

not easily restrained, and therefore sometimes prove suddenly fatal. 
But in other cases they are less copious; sometimes returning every 
day at stated periods, and sometimes less frequently, and at irregular 
intervals; and sometimes there is a slow and almost incessant oozing 
of blood. The bleeding occurs from the gums, nostrils, throat, inside 
of the cheeks, tongue and lips, and sometimes from the lining mem- 
brane of the eyelids, the urethra, and the external ear; and also from 
the internal cavities of the lungs, stomach, bowels, uterus, kidneys 
and bladder. There is the utmost variety, however, in different in- 
stances, as to the period of the disease, in which the haemorrhages 
commence and cease, and as to the proportion which they bear to 
the cutaneous efflorescence. 

u This singular disease is often preceded for some weeks by great 
lassitude, faintness and pains in the limbs, which render the patients 
incapable of any exertion ; but, not unfrequently, it appears suddenly 
in the midst of apparent good health. It is always accompanied by 
extreme debility and depression of spirits; the pulse is commonly 
feeble, and sometimes quickened; and heat, flushing, perspiration, 
and other symptoms of slight febrile irritation, recurring like the 
paroxysms of hectic, occasionally attend. In some patients, deep- 
seated pains have been felt about the praecordia, and in the chest, 
loins and abdomen; and in others, a considerable cough has accom- 
panied the complaint, or a tumour and tension of the epigastrium 
and hypochondria, with tenderness on pressure, and a constipated or 
irregular state of bowels. But in many cases no febrile appearances 
have been noticed; and the functions of the intestines are often 
natural. In a few instances, frequent syncope has occurred. When 
the disease has continued for some time, the patient becomes sallow, 
or of a dirty complexion, and much emaciated; and some degree of 
cedema appears in the lower extremities, which afterwards extends 
to other parts. 

" The disease is extremely uncertain in its duration ; in some in- 
stances it has terminated in a few days, while in others, it has con- 
linned not only for many months, but even for years. Dr. Duncan 
related a case to me, when I was preparing my thesis on this subject, 
which occurred in B hoy, who was employed for several years by 
the players at go(f to carry their slicks, and whose skin was con- 
stancy crowded with petechia;, and exhibited vibices and purple 
blotches whenever he received the slightest blow. Yet he was, in 
other respects, in good health. At length a profuse haemorrhage took 
place from his longs, which occasioned his death. When the disease 
terminates fatally, it is commonly from the copious discharge of 
blood, either suddenly effused from some important organ, or more 
slowly from several parts at the same time, A young medical friend 

of mine was instantaneously destroyed by pulmonary haemorrhage, 
while affected with purpura, m his convalescence from a fever, after 

he had '_; < > 1 1 < • into Lincolnshire to expedite Ins recovery; and I have 

•sen three instances of the latter mode of termination, in all of which 

there was a constant oozing of blood from the, month and nostrils, 

and at the same lime considerable discharge of it from the bowels, 
and from the lungs by coughing; and in one it was likewise ejected 



698 PURPURA. 

from the stomach by vomiting for three or four days previous to 
death. On the other hand, I lately saw a case of purpura simplex, 
in which the petechia were confined to the legs, in a feeble woman 
about forty years of age, who was suddenly relieved from the erup- 
tion and attendant debility, after a severe catamenial flooding." (P. 
104.) 

The result of the following highly interesting case of purpura 
hemorrhagica, shows in a marked manner the benefit of venesec- 
tion conjoined with purging. It is extracted from the first vol. of 
the Trans, of the Med. Chirurg. Society of Edinburgh : — A boy, aged 
6, of a week and strumous constitution, with swelling of the glands 
of the neck, and a slight inflammatory affection of the eyes, was ob- 
served to be particularly unwell on the 24th April 1823, and the two 
following days. He was dull, thirsty, with flushed face, and mani- 
fested an inclination to set near the fire. On the 27th, spots like flea- 
bites appeared on a great part of his skin, and soon increased con- 
siderably : some were small and red, and others large and of a purple 
colour. On the 2Sth, blood oozed from the mouth, with occasional 
bloody sputa. On the 29th, the urine became turbid, and of a red- 
dish colour ; he moved about occasionally, unwilling to remain in 
bed; and he even, on the forenoon of this day, walked a distance of 
at least a mile and a half for medical aid. Dr. Ebenezer Gairdner 
first visited this little patient on the afternoon of the 1st May, and 
saw at once that it was a distinctly marked case of the purpura 
hemorrhagica of Willan. The whole body, the anterior part of 
both thighs, the conjunctiva of the right eye, the tongue, the Schnei- 
derian membrane, were all affected with purple spots. Blood oozed 
from the gums, which were neither soft nor swollen; breath ex- 
tremely fetid: and Dr. Gairdner was told that he occasionally vomited 
blood. There was fulness, with pain on pressure in both hypo- 
chondria, particularly in the left; the abdomen was rather tumid, 
and affected with obscure pain; belly costive; urine free, and in 
appearance the same as before described. Pulse quick and sharp ; 
slight heat of skin. He seemed little oppressed, was attentive and 
acute, and expressed curiosity to know what were the marks on 
his skin. A saline cathartic immediately. Fifteen drops of dil. 
sulph. acid thrice a-day. To be bathed in tepid water morning 
and evening. 

May 2d. Passed a bad night. There were now considerable op- 
pression and hurried respiration. The hemorrhagic symptoms had 
increased, with more petechiae and vibices; pulse 110, wiry; skin 
hot and dry. Blood was immediately drawn to the extent of about 
10 ounces, when the boy became suddenly sick, and vomited. Con- 
siderable difficulty was experienced in suppressing the flow of blood 
from the wound, and during the remainder of the day he lost some 
quantity, which could not, however, be estimated, notwithstanding 
which the pulse, at 4 o'clock p. m., was 124 and wiry; the skin was 
also hot. He was afterwards drowsy, and slept quietly for three 
hours and a half. The tepid baths and acid drops to be continued, 
and a powder containing three grains of calomel and the same quan- 



PURPURA. 699 

tity of jalap to be given next morning, and repeated every three 
hours, until the full effect was produced. 

3d. Blood still oozing from the orifice in the vein ; there were less 
oppression and dyspnoea; the pulse, though quick and sharp, was 
less so than yesterday; tongue improved; little thirst; urinary and 
alvine discharges nearly as before. The acid drops, laxative pow- 
ders, and the tepid bath to be continued. 

4th. Pain under the os front is; ecchymosis of the eye greater; the 
pain in both hypochondria increased with considerable tension ; pulse 
124, firmer. Another bleeding was determined upon ; and when 
the bandage was loosened, the wound was still found open ; the part 
corresponding to the compress had become ecchymosed, but without 
swelling. At first the blood only oozed out, and soon flowed, but 
not very freely; the patient became faint, so that only two or three 
ounces were obtained. At evening visit, it was found that there had 
been some draining of blood from the orifice; but the patient was 
then in a quiet, sound sleep ; pulse the same as in the morning ; skin 
rather soft, and not very hot ; and it was stated, that lie had been 
asking for food in the course of the day. 

5th Passed since yesterday a good deal of urine, which was now 
pale and limpid ; pulse 10^ ; heal moderate; tongue clean and moist; 
gums still tender; and during the night there had been some oozing 
of blood from them, flas taken a little light nourishment with some 
relish. Bowels opened by the powders; the stools were excessively 
offensive, and very black-coloured; some increase of pain, with ten- 
sion of the abdomen, and in both hypochondria. Fomentations and 
small doses of castor oil. In the afternoon, the pain had increased, 
and he moaned much; during the day, several copious and grumous 
stools were passed ; and at 4 p. m. he seemed much distressed. A 
mixture, with an ounce of bark infused in a pound of port-wine, 
with an equal quantity of water, was then ordered to be exhibited 
in small doses; castor oil to be continued. In the evening he passed 
more black fiuces ; he was relieved from pain, and had some sleep. 

•<///. Passed a good night; little or none of the bark infusion had 
been taken ; he also refused the oil, therefore a laxative powder was 
ordered. The Bams dark-coloured fijeces were passed from the bow- 
els with less pain; no oozing of blood from the gums, nor in the 
sputa ; pulse 98; temperature of the skin natural. 

lt/t. Symptoms favourable. Much black fieees discharged. 

«//<. Stools of a natural appearance; petechias began to fade; 
pulse 96, not weak ; appetite improving. 

From tins time he recovered rapidly. On the 14lh he was out 
taking au. airing; and on lbs Kith he w;is running about, and his 
patents though! btUI to be in better health than he had been before 
lli«' accession of the present complaint 

The blood first drawn, coagulated very slowly, without separating 

any MI9JUI j Ofl the following day it looked like a tremulous jelly, the 

top being "i a greenish buii colour, Uiterspersed with brownish spots. 

That Which was attei -wards discharged had, as it came from the 

arm, more the appearance and consistence of turbid lymph, or fluid 

iu winch some reddish colouring matter was in suspension ; and the 



TOO PURPURA. 

cloths which were soiled did not present the usual stains of blood, 
but something like those of dirty water, interspersed with large stains 
of a reddish-brown colour. 

The reader is referred to the volume of the " Transactions," for an 
interesting account of the analysis of the urine. 

In the same volume of the "Transactions" will be found another 
interesting case of purpura, with an account of the traces of disease 
discovered on dissection. A girl aged twelve, of a scrofulous con- 
stitution, although otherwise in good health and spirits, with the 
exception of a chronic disease in her left wrist, was first observed 
on the 21st of June, 1823, to have a dark spot on her under lip, as 
if she had been putting a pen into her mouth. Next morning 
similar spots were observed thickly studded over her legs, and also 
a considerable number on her arms, but she made no complaint, and 
was amused at being thought sick, when she felt in perfect health. 
She walked about a mile, and returned with perfect ease. A laxa- 
tive prescribed. Next day she was sitting up, unconscious of ail- 
ment ; external appearance much the same as yesterday ; pulse 
good ; no heat of skin. Salts. About ten, on the evening of the 
22d, she asked for supper, and was allowed some bread and milk. 
During the night she had two stools; she felt faint and giddy with 
the last, and required assistance on returning to bed ; she was now 
seized with vomiting, and with a very severe pain in the right 
temple; the sickness was most distressing, and when raised up, 
vomiting supervened; the matter vomited was tinged with blood; 
and it was also observed, that the gums were readily excited to 
bleed. This was followed by great languor and exhaustion, and 
excited alarm of her immediate dissolution. Subsequently symp- 
toms of oppressed brain came on, and she died at 3 p. m. of the 23d. 

Dissection. — The appearance of the surface of the body remained 
unchanged. The pericranium was covered with petechial spots, as 
was the dura mater; on removing the membrane, the effects of a 
large effusion of blood were exhibited. In the right temporal region, 
a firm coagulum floating in bloody serum had forced its way through 
the broken down brain into the ventricle. The pleura and the peri- 
toneum were found like the dura mater, studded throughout with 
the dark livid spots. 

This case requires no comment. The patient had the able advice 
of Mr. William Wood of Edinburgh, a gentleman of great practical 
acumen, and large experience. It is evident, however, from the 
history of the case, that the bad symptoms came on suddenly about 
twelve hours before the death of the patient, in consequence of the 
effusion of blood which was afterwards found in the brain, and when 
no human means could have averted the fatal termination. How 
far a previous bleeding might have operated in preventing the cere- 
bral effusion, it is difficult to determine; but I must own, that were 
such a case to occur in my practice, now that I have had the advan- 
tage of reading the result of that related above, I should feel little 
hesitation in opening a vein. 

Another case of purpura hemorrhagica was communicated by 
Dr. Fairbairn to the Medico-Chirurgical Society of Edinburgh, in 



PURPURA. -01 

the second volume of whose " Transactions" it will be found re- 
corded, and from which the following brief extracts are made. 

The subject of this case was J. Henderson, aged 24, of robust 
constitution and regular habits. On the ISth November, 1S23, Dr. 
Fairbaim found him complaining of deep-seated pain in the left 
breast, aggravated by frequent fits of coughing, and by a full inspi- 
ration ; breathing hurried and laborious, with a distressing sensation 
of suffocation in the horizontal posture; countenance flushed and 
anxious. A copious discharge of dark venous blood oozed from the 
mucous membrane of the mouth, and a portion was also apparently 
expectorated from the lungs. Numerous petechia? and vibices were 
observed upon the arms, neck and trunk, but they were in greater 
number on the legs, varying in magnitude from a mere point to the 
size of a sixpence. There were also a few spots upon the forehead; 
some of the spots were of a bright red colour, others were purple or 
livid, and a few of a dirty yellow. In the mouth, similar spots oc- 
cupied the gums, cheeks, tongue and fauces ; the tongue itself was 
covered with a dark fur ; urine presented a grumous appearance ; 
pulse 110, firm and sharp ; increased heat; belly loose from a pow- 
der composed of jalap, which he had taken early in the morning. 

The patient stated that he had, for several weeks previous to the 
attack, experienced considerable depression of spirits, general lassi- 
tude and pains in his limbs, which were stiff and swollen at night. 
He also felt pains occasionally darting across his head and chest ; 
had a tickling cough, irregular shivering, followed by flushes of heat 
and partial perspirations. About the 12th Nov., six days before Dr. 
F. saw him, he first observed his sputa tinged with blood, which 
afterwards gradually increased. On the 16th, the discoloration of 
the skin made its appearance first on the legs, afterwards on his 
arms and trunk ; it was only in the morning on which Dr. F. saw 
him that the dyspnoea and other symptoms above described came 
on. Bled to 2<i oz. from the arm, which occasioned threatening syn- 
cope, wnh alleviation of the breathing, oppression and pain. No 
bully coat on the blood, which, however, presented a colour resem- 
bling arterial, and coagulated slowly without separating any serum, 

the coagulom being somewhat soil and tremulous, Prequent doses 

of 1.0 drops ofdU. sulph. acid to he given in cold water. 

1 '»///. Passed a restless night with fearful dreams and siartings; 
pectoral BymptOtns somewhat alleviated, though he still complained 
of a corded sensation across the lower part of the chest. Considera- 
ble oozing of blood from the mouth; urine grumous, and rather 
scanty; no stool ; pulse 1 12, and sharp; skin hoi; tongue furred and 
Streaked with blood. Eighteen ounces of blood were taken from 
the suae wound in the arm, which nearly produced Byncope, the 

I exhibiting the' same appearance as formerly. An ounce >>t 
i . 'Mi sails immediately. At 8 p. v., Dr. Pairbairn found that his 
patien|0iad had three boon of refreshing sleep in the course of the 
afternoon; hut there was no mitigation of the pain, dyspuoea, and 
corded sensation in the chest, One loose fetidstool from the salts ; 
OOaing of Wood from the mouth diminished ; urine grumous, hut the 

58 



702 PURPURA. 

quantity is increased ; pulse from 1 15 to 120, sharp and wiry; tongue 
dry and furred; skin rather moist. An ounce of castor-oil. 

20M. Had some intervals of sleep during the night, but awoke in 
great alarm ; experienced darting pains in the head, occasionally with 
slight delirium; frequent hiccup; pectoral symptoms the same ; very 
little discharge of blood from the mouth ; petechias more numerous, 
especially on the inferior extremities ; had two stools resembling 
pitch; urine scanty and grumous ; tongue dry and furred. Blood to 
the amount of £xx was drawn, which produced syncope ; buffy coat 
now apparent. A little wine and water, and beef-tea occasionally, till 
the state of collapse be removed, and subsequently decoct, cinchon. to 
be given in repeated doses. 

4 p. m. Had some intervals of sleep since the bleeding; is perfectly 
sensible, though he cannot articulate distinctly; pulse small and irre- 
gular ; skin covered with a cold sweat. The decoction had not been 
given as directed. Wine and beef-tea to be continued. 

At midnight Dr. Fairbairn found him in a comatose state, insensi- 
ble to surrounding objects ; the breathing laborious, with frequent 
heavy moaning, and he expired on the morning of the 21st, being 
the sixth day from the appearance of the petechias. 

The appearances on dissection, in this case, will be found at page 
316. 

The following is extracted from Dr. J. S. Combe's case of purpura 
hemorrhagica, detailed in the 17th vol. of the Edinburgh Medical 
and Surgical Journal, (page 83.) 

"19th Sept. 1820. Edward Canny, astat. 10. Skin universally 
covered with petechise of a dark brown, almost black colour, varying 
in size from that of a pin-head to one-third of an inch in diameter, of 
form nearly circular, but, on the lower extremities, less distinctly 
circumscribed, and pale. The tongue, gums and fauces, as far as 
can be seen, are studded with spots, but not so thickly as on the outer 
surface. There is a constant and pretty copious discharge of thin 
pale blood from the mouth and nostrils. The petechia? on the 
tongue bleed freely when touched. Pulse 116, small and rather 
sharp; skin hot; tongue white ; breathing hurried, but he is able to 
draw a full inspiration. Appetite not affected ; very thirsty ; has 
severe pains in head and legs ; very weak. 

"The spots were first observed two days ago in the morning, and 
on the evening of the same day blood began to issue from his mouth ; 
had passed a stool, in which bloody dots were perceived — ordered 
a brisk purgative, and 10 drops of acid, sulph. dil. aromat. thrice 
a-day. 

" 20th. Petechia? present various shades of colour ; blood oozing 
freely; pulse 120, small; had one stool, very fetid; skin hot, appetite 
good ; urine scanty, very thick. — Rep. pulv. purg. et cont. acid, 
sulph. dil. 

" 22d. A number of the spots have run into large vibices; discharge 
of blood equally copious, and much attenuated, pulse 120, fuller. 
Vomited a little blood twice ; complains of sickness on raising his 
head ; severe pain in the head ; bowels freely open ; stools dark- 
coloured, fetid; urine said to be high-coloured and sparing in quan- 



PURPURA. 703 

tity. Habt. iterum pulv. purg. et sumat. pulv. cinch. g« x. cum. acid. 
sulph. diij. g n vii. quarta quaque hora. Let hitn have an ounce of 
port-wine every five hours. 

"23rf. Slept ill; pain in forehead; nausea, and occasional retching; 
great debility. Pulse 1 10, small ; petechias and haemorrhage as before; 
bowels freely open ; urine scanty, turbid, and depositing a copious 
sediment; body emits a most offensive fetor. — Cont. omnia. 

"24M. He is in an alarming state; oppressed with nausea: vomits 
on the least exertion. Has not taken his medicines ; blood flowing 
more copiously from mouth ; petechias have gone into large clusters 
on forehead, arms and legs. Pulse 120, hard ; violent pain in the 
head; skin hot in the trunk, but cold on the extremities. Eight 
ounces of blood abstracted from external jugular vein. He became 
faint and vomited, and the pulse softer and fuller. The blood flowed 
in a small stream, and was of a very pale colour, more like the 
washings of flesh than common blood, coagulated slowly, without 
any separation of serum, and showed no buffy coat. — Ordered a 
purgative — discontinue the other medicines. On visiting him eight 
hours after, he was rather better ; sickness much abated, and no 
vomiting. Pulse 110, soft; headache easier; bowels opened three 
times ; stools more natural in appearance. There has been a copious 
flow of pale, limpid urine; the wound in the vein had not closed, 
from which he lost about Jjiss more of blood. 

25th, 8 a. m. Dr. Combe was called in great haste to stop the 
caustic applied to the wound. — In other respects decidedly better; 
voice stronger; countenance more animated; headache relieved; no 
bleeding from the jugular. The patient's clothes and bed-clothes 
were quite soaked with blood ; it was paler, and even more atte- 
nuated; no nausea or vomiting; urine very turbid. Ordered to be 
kept quiet, and to have any diet he chose, but no spirits. In the 
evening no blood had been discharged for the last two hours, either 
from wound or mouth. Habt. tinct. opii g* xx. h. s. et pulv. jalap, 
gr. xii. eras mane. 

" 1G///. Lost about 31 of blood from the wound during the night; 
slept well ; headache very slight; pulse 120. soft. No discharge of 
blood from nose or mouth; petechias fainter and more dill'iised. 
Bowels freely opened; stools natural; urine clear, and of a pale 
yellow colour. 

" 21th. Convalescent. From this time he went on doing well ; and 
the spots having altogether disappeared, he was discharged on 7th 
October." 

Causes of purpura.— According to Baleman, " the causes of this 
disease are |,y no means clearly ascertained, nor its pathology well 
understood." Twenty years have now elapsed since this statement 
was printed, and although many cases haVfl since occurred, and 

several have been minutely recorded with the appearances found on 

BCtiejTI, we are still perfectly ignorant both as to its causes and 

pathology. It has taken place m individuals who were strong, en- 
joying good health, breathing a pure country air, with all the neces- 
saries and comforts of life around them ; and il haa likewise attacked 

those ol de, hate habit, living m crowded situations on poor diet, and 



T04 PURPURA. 

subject to distress of mind ; and it has also occurred in others who 
were left in a state of debility by previous diseases, some of an 
acute, others of a chronic nature. 

In most of the cases which have been recorded, there has been 
severe pain or oppression in the chest, and in some in the head. In 
two cases, mentioned by Dr. Parry in the 5th vol. Ed. Med. and 
Surg. Journal, the blood was very much buffed; the proportion of 
crassamentum to that of serum was uncommonly great. In Dr. 
Fairbairn's case three bleedings were had recourse to — the first to 
twenty-six ounces, the second to eighteen, and the third to twenty; 
there was no buff on the two first; the blood was red like arterial, 
coagulated slowly, and separated no serum; but on the third bleeding, 
the blood showed a buffy coat. In Dr. Johnson's case, only a part 
of the blood drawn at the second bleeding exhibited a buffy surface. 

In different cases the pulse has been variously described — as full, 
70, full but not hard; 100, full and intermitting; quick, soft and 
small ; very quick and weak ; 100 and small ; 110, firm and sharp ; 
very hard and strong; 120, full. In almost all the cases the stools 
have been dark-coloured and fetid; some describe them as being of 
a dark green colour; and others, as black as pitch. 

Appearances on dissection. — Petechial marks have been dis- 
covered on the surface of all internal organs ; vascular turgescence, 
sanguineous and serous effusions have been observed in the head. 
The lungs have always been found diseased — congested in their 
substance, the air-passages filled with bloody effusion, and the mu- 
cous membrane lining the tubes of a dark colour. In the abdomen 
the mucous surface of the stomach and intestines has been found 
vascular, and spotted with petechiae ; the liver tender and more or 
less gorged. In one case mentioned by Dr. Bateman,the spleen was 
found enormously enlarged ; and in another instance there was a 
large morbid growth, consisting of a fleshy tumour with a hard car- 
tilaginous nucleus, weighing about half a pound, found in the situ- 
ation of the thymus gland, firmly attached to the sternum, clavicle, 
pericardium and surrounding parts. 

The following appearances were found in the case recorded by 
Dr. Fairbairn, thirty hours after death. 

" The petechial spots over the body exhibited nearly the same 
appearances as before death. The sides of the neck and upper parts 
of the chest were swollen and livid, and there was a feeling of crepi- 
tus, with considerable oedema over the trunk. On removing the in- 
teguments from the fore and lateral parts of the chest, the cellular 
and muscular textures were in some places injected with blood, and 
emphysematous. 

" The thorax contained about a pound of a fluid, resembling blood, 
of a very dark colour and viscid consistence. 

" The lungs were somewhat collapsed, of a dark livid appearance, 
and contained a bloody serous fluid which occupied all parts equally; 
there was much less feeling of crepitus throughout their substance, 
and the spongy texture was less observable than natural. The 
bronchial tubes and trachea were filled with a similar fluid; and, 
beneath the internal coat of the latter, there was a slight effusion of 



PURPURA. 7Q5 

dark venous blood, which tinged the membrane of a deep purple 
shade. Between the folds of the anterior mediastinum and of the 
pericardium, there was effused into the cellular texture a considerable 
quantity of very dark blood, mostly in a clotted state, amounting 
to several ounces by computation. The pericardium contained the 
usual quantity of lubricating fluid ; the inner surface presented its 
natural, smooth, glossy texture, but it had assumed anteriorly a deep 
or brownish-red colour, from the effused blood between its layers 
shining through it. The heart appeared pale and flaccid; there was 
no blood in any of its cavities. Under its internal membrane, parti- 
cularly towards the valves of both sides, but more copious in the 
left, there was a similar effusion as in the trachea, giving a deep 
livid colour to the surface of the heart, and tinging its substance to 
the depth of half a line or a line. 

"The inside of the aorta presented an increased tint of redness, 
apparently from the same circumstances, without evident thickening 
or change of texture. 

" In the cavity of the abdomen the floating viscera were of a dark 
leaden colour, and less vascular than natural. 

" There were a few petechiae on the intestines. In the ileum there 
was slight inflammation, extending for a couple of inches, where one 
portion of the bowel had passed within another. 

" In the stomach, towards the pyloric extremity, its inner mem- 
brane was thickly studded with petechiae; whereas that portion 
surrounding the cardia, for about three inches, was distinctly em- 
physematous. 

"The liver was paler than usual, and somewhat softened; its 
peritoneal proper coat was very easily peeled off; from its internal 
surface a bloody, serous fluid could be squeezed out. The spleen 
was of full size and softer than usual ; and, when torn, effused a 
quantity of dark-coloured matter of a semifluid consistency. 

u The right kidney seemed softer than natural; there was an effu- 
sion of blood under the internal membrane lining its pelvis, similar 
to that on the inside of the heart. The left appeared peculiarly 
blanched, and was also soft.; but there was here no effusion. 

"The bladder was pale and contracted, containing a U-w ounces 
of the same turbid-coloured urine as be had been lately passing. 

••On removing tin: scalp there were two large ecchymoses, two on 
each side, over the superior attachments of the temporal muscles. 
The brain, with its membranes, appeared quite, healthy; there might 
be about an ounce or so of clear serum in the ventricles and at the 
base of the brain. 

" In the course of dissection it was remarked that there was a full 
proportion of adipose BUbStance in every part of the body." 

Pathology 0/ purpura. — After relating two cases of purpura iii 
the .'>ih vol. of the Kd. Med. .Journal, the one occurring in a lady 

nbout 60, the other in a colonel of the army, who had been rather a 

free hver. Dr. Tarry observes: u These cases strengthen an opinion 

which I more than twenty years ago maintained, and which a large 

subsequent experience has tended m confirm-— that, in various dis- 

-, among which may he reckoned inflammations, prolluvia, 



706 PURPURA. 

hemorrhages, dropsies, exanlhemata and other cutaneous eruptions, 
and even the generality of nervous affections, there is one circum- 
stance in common, which is an over-distension of certain blood- 
vessels, arising, probably, from their relative want of tone, or the 
due contraction of their muscular fibres." 

Dr. Duncan, jun., in the 72d number of the Edinburgh Journal, 
conceives that this disease may probably arise from the following 
circumstances: — 

" 1st. Increased tenuity of blood, allowing it to escape from the 
superficial extremities of the minute arteries. 

" 2d. Dilatation of the mouths of those arteries, allowing natural 
blood to escape. 

" 3d. Tenderness of the coats of the minute vessels, which give 
way from the ordinary impetus of the blood. 

" 4th. Increased impetus of the blood, rupturing healthy vessels. 

" 5th. Obstructions in the vessels, causing rupture, with natural 
impetus, and without increased tenderness. 

" 6th. Two or more of these causes may act simultaneously or 
successively." 

Mr. Plumbe thinks that Dr. Duncan's third conjecture is unques- 
tionably correct as regards the formation of cutaneous spots of pur- 
pura. " That this tenderness is the result of deficient nourishment 
in the superficial vessels is, perhaps, equally clear; and it may fairly 
be suspected that such deficiency is consequent on the congestion in 
the hepatic and gastric circulation." 

My own experience in this disease has been very limited, but 
after a careful review of the whole subject, 1 cannot subscribe to 
Mr. Plumbe's opinion, for the two following reasons: — 1. If the dis- 
ease had any necessary connection with tenderness of the vessels, 
the consequence of deficient nourishment, it would be of far more 
frequent occurrence, whereas it is avowedly rare. 2. It is my im- 
pression that the state of the lungs in all stages of the disease, and 
more particularly in the early stages, has been hitherto quite over- 
looked. In one rapidly acute case which I was called to see, and 
which terminated fatally, the rale crepitant was heard in some 
parts of the chest, and the rale muceux in others. Although I have 
not been able to determine the true pathology of the disease, I think 
it possible that it may be owing to general functional derangement 
of many organs, which at last produces a great change upon the 
blood; and that it may be owing probably to disease primarily 
seated in the lungs. 

It is pretty generally admitted that there is considerable analogy 
between the purpurous spots and the petechial which sometimes 
take place in fevers, in which there are also occasional discharges of 
blood from various organs; and I can state with the utmost confi- 
dence, that since my attention became directed to the investigation 
of the probable causes of petechiae, I have not in one instance failed 
in detecting disease of the lungs, and particularly of the mucous 
membrane, by auscultation, and that the observations so made have 
been confirmed upon examination after death. 

Treatment of purpura. — Under the mystery which at present 



PURPURA. 707 

involves the nature and seat of purpura hemorrhagica, it is im- 
possible to enter upon this part of the subject without a feeling of 
embarrassment. Dr. Parry and others have, from certain notions, 
strongly supported venesection, while it has been condemned by 
some practitioners whose opinions are entitled to at least equal re- 
spect. Dr. Willan is one of those who recommended "a generous 
diet, the use of wine, Peruvian bark and acids." There is one 
point, however, on which almost all practitioners agree, viz.: the 
advantage of keeping up a free discharge from the bowels. 

It is strongly impressed upon my mind, from a review of the cases, 
that there are some instances like those recorded by Dr. Parry, Dr. 
E. Gairdner and Dr. Combe, in which the patient's only hope of 
safety depends upon venesection; and that there are other instances, 
as those probably from which Dr. Willan drew his practical conclu- 
sions, which require an opposite mode of treatment. Daily experi- 
ence also convinces me that there is a third set of cases in this, as in 
almost all diseases, which requires a combination of bleeding and 
stimulants, and that it is not inconsistent with sound notions of pa- 
thology to bleed first, in order that we may be able to stimulate, and 
to stimulate for the purpose of enabling us to draw blood. Bleeding 
is always a dangerous remedy when employed late in severe dis- 
eases ; and I fear considerable errors have happened from drawing 
blood too late in purpura. A few years ago, 1 directed a vein to be 
opened in the arm of a girl affected with purpura ; she died the same 
night ; and in Dr. Fairbairn's case, the man, although previously 
strong, never recovered from the last loss of blood, and died in a few 
hours afterwards. The particulars of the case which I attended 
should have been detailed, but I was not allowed an opportunity 
of examining the body of the patient after death, although every 
exertion was made to obtain it. The case was so similar to others 
already published, that it is of no value without a minute dissection- 
report. 

When the operation of bleeding is performed, a larger orifice 
should not be made than is actually necessary, and the patient ought 
to be visited at short intervals, as subsequent haemorrhage frequently 
occurs from the vein, and a good deal of difficulty is sometimes ex- 
perienced m suppressing n. The jugular ought not to be opened, 
unless in a case similar to Dr. Combe's where no vein was found in 
the arm. 

A< Ms, particularly the mineral, have been highly recommended; 
but 1 am disposed to place more confidence in the vegetable, and 
especially fresh lime-juice, not only taken internally, but applied 
externally. Turpentine has also been found useful by Dr. Nicholl: 
vide 17th vol. Edinburgh Medical and Surgical Journal. 

from the beneficial effects produced by the acetate of lead in other 
,i am induced to hope it may be found serviceable in pur- 
para be morrhagica. 

Since writing the above, I was called to sec a child, between two 
and three rears of age, who lived in the same room with two other 
children affected with genuine small-pox. I found it feverish and 
lethargic, with constant vomiting ; it had several petechial spots, and 



708 PURPURA. 

although it had gone through the process of vaccination when a few 
months old, I was apprehensive of small-pox. Laxative medicines 
were ordered. 

Next day the child was found in the same state. The petechial 
spots had increased in number and size, and had spread over the 
trunk and extremities ; the skin was hot, and the pulse quick and 
strong; nothing was retained on the stomach; several attempts were 
made to give laxatives, but even small quantities of calomel were 
immediately vomited. Four leeches were applied to the instep. 

On the third day the child was found convalescent; the leeches 
bled profusely ; and although a tight bandage had been applied as 
directed, still the greatest difficulty was experienced in restraining 
the haemorrhage. No petechial spots were now to be seen; but 
the foot was ecchymosed from the pressure of the bandage, on the 
removal of which blood again began to ooze from the leech-bites, 
which made it necessary to re-apply the bandage. There had been 
no stool for three days ; but as the irritability of the stomach had now 
subsided, laxative medicines were given, the bowels were moved 
before night, and so little debility was produced that the child was 
walking about the room on the third day. 

At the very moment I was engaged in completing this article for 
the first edition, I was favoured with a letter from Dr. J. S. Combe, 
in answer to a communication from me on this subject ; from which 
the following cases are extracted. They are very interesting, as in 
both instances the disease occurred in connection with general acute 
rheumatism: — 

" A remarkable case of purpura was pointed out to me (says Dr. 
Combe) by the late Dr. Kellie. The subject was a brewer's servant, 
big and plethoric, who, on the fourth day of an attack of acute and 
general rheumatism, was found covered with bright petechial spots ; 
he also discharged some blood from the bowels. Active depletion 
was had recourse to, and he made a quick recovery." Dr. Combe 
further states, that he " lately saw a robust girl, aged 5, who had 
been attacked with a violent convulsive fit, and on recovery com- 
plained of severe pain of head. In the course of a few hours I saw 
her, and as small-pox prevailed in the neighbourhood, her friends 
considered it as such, and pointed out some spots on the skin ; they 
were undoubtedly petechial, and covered nearly the whole body, 
with smart fever and vomiting. On the third day the extensor 
muscles of the head were so painful that she could not bend it for- 
ward without much suffering; in a few hours this was followed by 
acute pain of all the larger joints. The spots on the fifth day were 
fainter in colour, and disappeared in a few days after ; but eight 
days more elapsed before the rheumatic affection had subsided. She 
was treated actively by venesection and purgatives." 

Exudation of blood from the surface, ivithout abrasion of the 
cuticle, commonly called Bloody Sweat. 

Perhaps nearly allied to purpura is the transudation of blood from 
some parts of the surface of the body, which, in all the cases I have 



PURPURA. 709 

heard of, has attacked females. It is a rare disease, and has been 
observed to be for the most part vicarious with the menstrual dis- 
charge. 

In the former editions of this work, a very interesting history of a 
case of exudation of blood from the surface of the body was detailed; 
but I have since had reason to believe the girl was an impostor, and 
that she has deceived many medical gentlemen, to excite sympathy 
and obtain money. 



PART VIII 



DISEASES OF THE URINARY AND GENITAL ORGANS. 



CHAPTER I. 



INFLAMMATION OF THE URETHRA, BLADDER, AND 
KIDNEYS. 



INFLAMMATION OF THE URETHRA. 

Under this head I shall treat of gonorrhoea; for although inflam- 
mation of the mucous membrane of the urethra may be produced by 
external injuries and other causes, yet this is rare in comparison to 
the disease produced by impure contact. 

Gonorrhoea, (known also by the term blenorrhoea,) is an inflam- 
matory affection of the mucous membrane of the urethra, the conse- 
quence of impure coition, and of which there are a great many 
varieties. The symptoms vary according to the extent and intensity 
of the inflammation, the peculiar constitution of the patient, and 
perhaps, also, the condition of the matter applied. A disease resem- 
bling gonorrhoea, may, it is said, be produced by inflammatory ac- 
tion extending from the kidneys and bladder — by calculi, highly acrid 
urine, excessive indulgence in sexual intercourse,long-continued abuse 
of spirituous liquors, the action of cantharides on the system, and the 
incautious introduction of instruments. 

Symptoms and course of gonorrhoea. — A short time after impure 
connection, a sense of titillation is felt in the urethra, which soon 
amounts to itching, and is attended with frequent desire to make 
water. There is a feeling as if some urine were still left in the ure- 
thra, and a consequent effort is made to discharge it; the orifice is 
now observed to be red and swollen, and perhaps a small quantity 
of discharge is seen. By and by the desire to make water is more 
frequently renewed, and on each occasion the passage of the urine 
becomes more painful, sometimes almost intolerable, while the stream 
becomes smaller, notwithstanding the increased impulse given by the 
patient in bearing down. A pretty copious discharge of matter soon 
takes place from the urethra, which augments for some days, becomes 
thicker, puriform in appearance, and yellowish in colour; but when 
the inflammation is intense, it is greenish, and sometimes tinged with 
blood. It is denied that the matter is pus; we shall, however, com- 
mit no error if we consider it as a pnnlorm fluid, analogous to that 
which is discharged from the inflamed surface of other mucous mem- 
branes. I'll'' gfcldl and prepuce frequently become swollen, and 
although the swelling of the prepuce is generally owing to oedema, 
yet it is sometimes occasioned by the extension of inflammation from 
60 



714 INFLAMMATION OF THE URETHRA. 

the glans. Often, during the course of this disease, there are excess- 
ively painful erections, particularly during the night, the penis being 
sometimes bent one way, sometimes another, which condition is 
termed chordee. This disease generally goes on increasing in vio- 
lence to the seventh, and sometimes even to the fourteenth day, and 
I have known the acute stage to continue even to the thirtieth. The 
decline of the acute stage is marked by the diminution of the ardor 
urinse and the inflammation at the meatus; still, however, the dis- 
charge of puriform fluid may continue considerable under the chronic 
form of inflammation. Every act of sexual indulgence, the use of 
ardent spirits, errors of diet, the application of cold, and inattention 
to the bowels, frequently produce acute inflammatory action, by 
which means the disease may be prolonged for a considerable length 
of time. 

This is a description of the disease as it usually occurs. Sometimes, 
however, it is seen in a much milder form, so much so as to give the 
patient little trouble, and occasionally appears to undergo a sponta- 
neous cure. But there is a far more severe form of this affection, in 
which the pain, and probably the inflammation, extends throughout 
the whole urethra, affecting, in some cases, even the bladder, and 
occasioning pain in the loins; the calibre of the canal is very much 
diminished in consequence of the swollen state of its mucous mem- 
brane, and notwithstanding all the efforts which the patient can ex- 
ert, the urine flows drop by drop, accompanied by most excruciating 
pain, and chordee is frequent and distressing. In the worst cases, 
Cowper's glands and the prostate partake of the inflammation, when 
a sense of heat, weight and fulness are felt in the perinaeum, gene- 
rally accompanied by dysuria and tenesmus, which more frequently, 
however, occur when the disease spreads to the neck of the bladder. 
This state occasionally terminates in abscess, fistula and permanent 
disease of the prostate. But a more frequent termination of gonor- 
rhoea is stricture of the urethra, produced by a permanent thickening 
of the mucous membrane, or by an extension of the inflammation to 
the cellular tissue surrounding that part of the urethra most intensely 
affected. During the course of gonorrhoea, even when very slight, 
inflammation of the testes occasionally takes place, and also of the 
glands in the groin; and sometimes an herpetic eruption is produced 
upon the glans or prepuce, probably from the acrid nature of the 
matter. 

The term gleet is used to express the existence of a discharge from 
the urethra, the consequence of a diseased condition in which the 
mucous membrane is left after acute inflammation. This discharge 
is generally attributed to chronic inflammatory action ; it comes and 
goes, varies in appearance between serum and pus, but for the most 
part is muco-purulent. The least error in diet, the use of spirits, 
wines, acids, fruits and peppers, is followed by frequent desire to 
make water, some ardor urinse, and increased discharge of matter ; 
sometimes these symptoms exist to such a degree as to make the pa- 
tient himself believe that it is a fresh attack. This state increases 
year after year till at last a permanent stricture is formed. Loss of 
health is often the consequence of disturbed nights, produced by pains 



GONORRHOEA. 715 

in the lower extremities, and by the patient being obliged to rise 
many times out of bed to empty the bladder, perhaps to void only 
an ounce of urine. Thickening of the bladder follows, with disease 
of the prostate, and perhaps, also, of the kidneys. 

Symptoms of ' gonorrhtea in females. — The chief differences pro- 
duced by this disease in the male and female are the following: In 
the latter, the inflammatory action sometimes affects the mucous 
membrane of the vagina; and I have seen several cases where there 
was reason to believe that the lining membrane of the uterus also 
became involved, giving rise to leucorrhcea and menorrhagia in 
their worst forms. From the small extent of the urethra in the fe- 
male, which does not exceed an inch and a half in length and the 
simplicity of its structure, the symptoms upon the whole are not so 
distressing at the time as in the male, but the disease often leaves a 
severe form of prurigo, affecting the labia, the nymphae and the 
clitoris. 

I shall not stop to inquire whether this disease is, or is not, con- 
nected with syphilis, or whether it ever had a syphilitic origin. 

. Ippearance of the urethra when affected ivilh gonorrhoea. — 
Few opportunities of examining the state of the urethra in this dis- 
ease present themselves. Sir Astley Cooper, however, had once such 
an opportunity in a criminal who had gonorrhoea at the time of his 
execution. " The inflammation had extended down to the bulb of 
the urethra ; for an inch or an inch and a half down the urethra was 
exceedingly red, and there was some effusion of matter on the inter- 
nal surface ; the urethra was also red at the bulb but not of so deep 
a colour. The inflammation, therefore, (says he,) is not always con- 
fined to an inch, or an inch and a half down the urethra, but often 
extends over the bulb, and in this way produces strictures." In the 
case above alluded to, the gonorrhoeal inflammation had extended 
seven inches down the urethra. Sir Astley Cooper thinks the inflam- 
mation to be of the erysipelatous kind, and that ulceration does occa- 
sionally take place in the mucous follicles, but never in the urethra 
: if that were the case, the mucous membrane would more fre- 
quently give way. (Vide Lectures, p. 462.) 

Treatment of gonorrhata.—TlriB is, in many cases, a very in- 
tractable disease, and there is no telling where it will end. I have 
more frequently been annoyed and disgusted in conducting the treat- 
ment d| gonorrhoea than of ai;y other affection. We are often not 
lilted till the disease is far advanced, and great difficulty is expe- 
rienced in keeping this class of patients under a proper degree of re- 
straint. 

There are two methods of treatment strongly recommended. — The 
one is to endeavour to alter the action of the part immediately, even 
during tin- acute stage, by means of stimulating injections, or the ac- 
tion of CUbeOS, a remedy Which was introduced into tins country a 
few years ;i'_'o from the island of Java, There can he no doubt that 
CUbebs \i :i very powerful, and, in many instances, an excellent re- 

medy ; hut had consequences, it cannot he denied, are often produced 
both by u ami stimulating injections when indiscriminately used. 

Tinre appears to be a tune at ihe very commencement of the Inst 



716 GONORRHOEA. 

stage of the inflammation, when either remedy may prove beneficial, 
but this must be during the first hours, before the inflammation has 
extended, and previous to the formation of matter; but we seldom 
have such an opportunity. Were a medical man himself the patient, 
he might, indeed, apply these remedies at once, and successfully, par- 
ticularly if his habit of body were in a good state at the time. Cures 
appear to have been effected when the first stage had been further 
advanced ; but, perhaps, for one such event, there have been fifty fail- 
ures, out of which several cases might be produced, where more vio- 
lent inflammation and suppuration of the parts, and even inflamma- 
tion of the testes, succeeded. Therefore, generally speaking, it is not 
in the first stage that these remedies are found to be so advantageous 
as in the chronic. 

The other plan I shall give in the words represented to have been 
used by Sir Astley Cooper in his lectures: — " When the patient ap- 
plies to you for his first clap, there will be generally a great deal of 
inflammation, and I advise you to give the sulphate of magnesia 
with the infusion of senna. An ounce of the sulphate of magnesia 
may be mixed with six ounces of the infusion of senna, and three 
tablespoonfuls given two or three times a day, so as to purge the 
patient very actively. You may afterwards give the submurias 
hydrargyri with extract of colocynth, but merely as a purge; for if it 
were to act as a mercurial, I would not give it at all. There is no 
necessity for giving calomel, unless you wish it to act on the liver, as 
well as on the intestinal canal. Having purged the patient pretty 
freely, you will direct him to take diluting drinks, of which he can 
hardly take too much. Two drachms of the carbonate of potash or 
the subcarbonate of soda should be taken in a quart of some dilut- 
ing drink in the course of a day : capillaire or tea will answer this 
purpose very well: some advise the gum of acacia, but whether it 
does any good or not, I do not know. 1 have found the liquor calcis 
a very excellent diluent in this disease. Soda water is often useful, 
but it must be ascertained whether it produces irritability of the 
bladder; for, in some persons, it increases irritability. If it increase 
very much the inclination to make water, it should not be persisted 
in; if it do not produce this effect, it is a very excellent diluent. 
The penis should be suffered to hang for a considerable time in warm 
water, which will relieve the inflammation, and produce nearly all 
the good of a warm bath. When the ardor urinss and pain from 
chordee are very severe, twenty drops of the liquor potassas, with 
from three to five grains of the extract of conium, in the mistura 
camphorata, may be given with considerable advantage. This is 
the plan which you should pursue during the first week. You may 
then apply lint, dipped in the liquor plumbi subacetatis dilutus, to 
the part. Do not use an injection in the first instance, but pursue 
the plan I have pointed out to you during the first ten days." 

Having frequently tried this plan of Treatment without success, 
I had recourse to that which shall now be described, and I can re- 
commend it strongly from its superior success. 

1*/ Stage. — If the inflammation be severe and extensive, with 
much ardor urinas, swelling of the penis and chordee, I open a 



GONORRHOEA. 717 

vein, particularly if the patient be young and robust, and if the 
pulse be full or hard, and in this manner make a speedy impression 
upon the inflammation. The bleeding is to be followed by the use 
of saline purgatives, given after the exhibition of a moderate dose 
of calomel combined with any other laxative in common use, the 
antiphlogistic regimen, and, perhaps, also a solution of tartar-emetic. 
By these means, the severity of the inflammation will, in general, be 
quickly subdued, and the first stage shortened. After this I have 
often seen the greatest advantage from the immediate employment 
of cubebs, the balsam of copaiva, as well as from astringent injec- 
tions thrown into the urethra. In some cases where bleeding is 
inadmissible, and where the inflammation produces pain in the peri- 
naeum, much benefit may be derived from the repeated application 
of a dozen or two of leeches. Jlrdor urinas, dysuria and chordee 
are most effectually mitigated, in cases not requiring the active treat- 
ment above recommended, by linseed tea containing a small propor- 
tion of the nitrate of potass, as also by anodyne injections thrown 
into the rectum. A very useful remedy is to be found in pills com- 
posed of equal parts of camphor and hyoscyamus, of which two may 
be taken every second, third or fourth hour, till the patient be re- 
lieved. 

The tinctures of muriate of iron and iodine have been much 
praised. 

2d Stage. — It frequently happens, however, that we are not con- 
sulted till the second or chronic stage has taken place. Even then, 
I have seen considerable advantage from the application of leeches 
to the perinaeum, more particularly in old subjects, and when the 
inflammation had extended far down the urethra. It is in this stage 
that the effects of cubebs, balsam of copaiva and astringent injec- 
tions are so beneficial, provided there be no tendency to stricture, to 
ascertain which, a bougie is to be introduced; and if one should be 
discovered, it will be in vain to use any remedy till it be removed. 
The usual injections employed are those composed of the acetate of 
lead or sulphate of zinc, at fust in about the proportion of a grain 
to the ounce of water. Sometimes these substances are united, 
forming a solution of the acetate of zinc, the sulphate of lead being 
precipitated; the solution should be carefully strained before using. 
An infusion of green tea is also often serviceable. An essential oil of 
copaiva has been introduced into the practice, but it is by no means 
ascertained whether it possesses any advantages over the common 
balsams. An agreeable method of using copaiva is by making equal 
parts of the balsam and essence into pills, with the carbonate of mag- 
nesia, sixteen or eighteen of which are to be taken daily. 

In treating the disease in females, the same principles are applica- 
ble ; and when injections are ordered, care should be taken that they 
be not thrown mio the vagina only, which generally happens unless 
instructions are given where to find the urethra. It has been men- 
tion^! already] that :i troublesome prurigo sometimes affects the 
labia, DymphSB ami clitoris, for the cure of which, it is necessary to 
pay great attention to the bowels, to use ablutions of the parts every 
second or third hour, with astringent washes ; and in obstinate cases, 

60' 



718 INFLAMMATION OF THE BLADDER. 

the application of a solution of the nitrate of silver is necessary. 
Confinement to the horizontal posture, and even general bleeding 
are called for, particularly when the parts are inflamed and much 
swollen. 

INFLAMMATION OP THE MUCOUS MEMBRANE OF THE BLADDER. 

This disease most frequently affects the neck of the bladder, and 
is generally recognized by pain and swelling in the hypogastric 
region, the pain being increased by pressure, with a sense of internal 
heat and tension, frequent desire to make water, and extreme diffi- 
culty in passing a few drops, notwithstanding violent bearing down 
efforts; occasionally, indeed, there is complete retention. There are 
also considerable pain and burning heat in the urethra, sometimes, 
however, only at its orifice, with a sense of itching in its course. 
The bladder sometimes becomes greatly distended, and, indeed, it 
may be mentioned that the distension is sometimes the cause of the 
inflammatory action. If the disease is not soon mitigated, tenesmus, 
tympanitic distension of the abdomen,, pains in the loins and febrile 
symptoms take place. 

There is also a chronic form of inflammation of the bladder, which 
occurs in old people, and is often occasioned by stone, which termi- 
nates in thickening, and even ulceration of the mucous membrane, 
with very considerable hypertrophy of the muscular structure of the 
organ ; and it is in these cases that the discharge of a large quantity 
of mucus takes place. 

This disease terminates by what is called resolution, and by be- 
coming ehronie, when pus is sometimes discharged. Gangrene is 
exceedingly rare ; peritonitis is a more frequent occurrence, owing 
more to the distension of the bladder than to the extension of the 
inflammation from one tissue to the other. Ulceration is rare. 
There is a fine specimen, however, of this termination of inflamma- 
tion of the bladder, in my museum, which I owe to Mr. Fraser, 
surgeon of the flag ship of Admiral Napier. The subject of this 
interesting case was a Portuguese sailor, Francisco Jose, aged 40. 
The following statement is extracted from Mr. Eraser's communi- 
cation: 

" He complained of pain in the epigastric region, on 25th March 
at 7 p. m. — Stated that he had not voided urine for eighteen hours. 
Pulse feeble. On introducing the catheter, about one ounce of bloody 
urine was evacuated. Fomentations to the abdomen. Ten drops 
of muriated tincture of iron were given occasionally. 

" 26th. — Pain still continues, but is not aggravated by pressure. 
Much distension of abdomen; no urine voided since last report. 
The catheter again introduced, and a very large quantity of urine 
was evacuated. Fomentations continued, and an ounce of castor-oil 
exhibited. 

" 2 p. m. — Bowels not opened by the oil. Pain is now increased on 
pressure, gss f oil repeated, with 3i of sweet spirit of nitre ; large 
poultice to abdomen. 7. 50. No alteration in symptoms. Again 
relieved by the catheter. 



INFLAMMATION OF THE BLADDER. 719 

"27M. Passed a good night. Pain of abdomen relieved. Bowels 
freely opened. Pulse still feeble. 6 p. h. Declared that the medi- 
cine could do him no good, and that he would soon die. Has walked 
about during the day, and there was nothing very remarkable in his 
appearance indicative of danger. 

"At 7 p. m., he was moribund, and died soon afterwards. 
" 2Sth. Sectio cadaveris. — Viscera of abdomen and thorax healthy. 
About a pint of urine was found in the abdomen. The peritoneum, 
nevertheless, presented a healthy appearance. There was no un- 
usual vascularity, no effusion or adhesions. The bladder very much 
contracted, presented an ulcer, about three-fourths of an inch in 
length, at the fundus, forcing a free communication between the 
cavity of the bladder and the abdomen. The prostate gland of na- 
tural size, and healthy in appearance." 

Causes of inflammation of the bladder. — Individuals subject to 
gouty and cutaneous diseases, as well as those affected with dyspep- 
sia, are liable to this complaint. The application of cold ; the use and 
particularly the abuse of ardent spirits; the external or internal use 
of cantharides and small doses of turpentine, together with acrid 
urine, are also occasional causes of this disease, particularly in indi- 
viduals who are alllicted with strictures in the urethra. 

Treatment of inflammation of the bladder. — Bleeding, general 
and local ; the hip-bath, gentle laxatives frequently repeated, emolli- 
ent and mucilaginous diluents and opiates, particularly per a?ium, 
ought to be had recourse to, according to the severity of the disease 
and sufferings of the patient; but the introduction of the catheter 
into the bladder must be regarded as a principal remedy, and ought 
to be had recourse to as soon as possible. This is not only servicea- 
ble by drawing off, perhaps, a large collection of water, thereby re- 
lieving the distension, but sometimes by removing a small quantity 
of acrid, high-coloured urine, which mitigates the patient's sufferings 
immediately. In this case, also, the employment of camphor and hy- 
oscyainus will be beneficial; and when the disease becomes chronic, 
I have seen cubebs and copaiva useful. In instances where we 
have good evidence that acrid urine is the cause of the disease, it 
will be found serviceable to inject tepid water into the bladder, pro- 
vided it is not allowed to be retained; this means is also recommend- 
ed when tin: inflammation becomes chronic. Rubefacients are ser- 
viceable, both in acute and chronic inflammation of the bladder. 
Tincture of cantharides given internally, and small doses of turpen- 
tine are beneficial in some cases, but are to be used only in chronic 
forms of the complaint of long standing, when we want to rouse a 
little action. It Deed scarcely be staled, that after there is evidence 
of stone in the bladder, the first opportunity should be seized, which 
the local and general symptoms will admit, to extract it by the usual 
surgical operation. 

[The most frequent form of this disease follows the application of 
blisters, and ii familiar by the name of strangury. In addition to 

the remedial already mentioned, externa] fomentations to the hypo- 
gastric region should not be omitted; or what is still better, the ap- 
plication of a bladder half full of hot water, between which and the 



720 INFLAMMATION OF THE KIDNEYS. 

skin, a fold or two of flannel may be at first introduced. But in this, 
as in other diseases, prevention is better than cure ; and after having 
witnessed much suffering from blisters, I have adopted the plan of 
guarding them by means of camphor and opium: thus, in a blister 
five or six inches square, I direct twelve grains of the former and 
four of the latter to be rubbed up with the ung. cantharid. before 
spreading it; and I unhesitatingly assert, that since I adopted this 
precaution, I have never met with a severe case of strangury, and 
very rarely with even a partial one.] 



INFLAMMATION OF THE KIDNEYS. 

The term nephritis has been applied to this disease, the causes of 
which are much the same as those of inflammation of the bladder. 
Gouty subjects, and others who are frequently troubled with rheuma- 
tism and lumbago, and also with eruptions, are often affected with 
nephritic complaints, as well as those who are subject to dyspepsia. 
The abuse of spirituous and malt liquors, the too frequent use of diu- 
retics, the employment of cantharides, sudden changes of tempera- 
ture, suppression of habitual discharges,and the recession of eruptions, 
retention of urine, external injuries, irritation produced by the pre- 
sence of a calculus in the kidney, and inflammation of the urethra 
and bladder, extending to the kidneys by continuity of surface, are 
all exciting causes of the disease. 

Symptoms of inflammation of the kidneys. — This disease gene- 
rally commences, like other inflammations, with rigors, followed by 
pain and fever, which vary in intensity. The pain is generally 
severe and lancinating, but sometimes is obtuse, with a sense of in- 
creased weight, which is felt in one or both lumbar regions ; it often 
extends to the bladder, the penis, the groins and scrotum, and some- 
times even to the thighs ; and is increased by pressure and motion, 
as well as by taking in a full breath, and efforts made at stool. In 
slighter cases the patient complains only of a sensation of heat and 
weight, sometimes of gnawing constrictions in the loins. The urine 
is scanty, and passed drop by drop, of a red colour, and sometimes 
is entirely suppressed. Besides these symptoms, there are often a 
feeling of faintness, nausea and bilious vomiting, borborygmus, op- 
pression at the praecordia, hiccup, tympanitic distension of the abdo- 
men ; occasionally there is diarrhoea with tenesmus; at other times 
the bowels are constipated, and numbness and retraction of the tes- 
ticle on the affected side are complained of; — if both kidneys be 
affected, there is retraction on both sides. There is likewise fever, 
and the pulse is generally hard. Sometimes the skin is covered with 
perspiration having a urinous smell ; at other times it is dry and hot. 

These symptoms are often variously combined, and are sometimes 
modified by the occurrence of great restlessness, headache, and the 
passage of bloody urine, which, however, on some occasions, is clear 
and limpid, although it may subsequently deposit a white sediment. 

This disease is rarely fatal, although the bodily pain is, perhaps, 
fully as intense as in any other malady— the product of inflamma- 



[ALBUMINURIA.] 721 

tion and accompanied by fever. It rarely terminates in extensive 
suppuration in the substance of the kidney, but I have sometimes 
seen small abscesses in individuals who died of the ordinary fevers of 
this country, which were treated as typhus fevers, and where no 
suspicion was entertained during life that any local disease existed. 
Sometimes the matter escapes and finds its way into the pelvis of the 
kidney, and from thence into the bladder; on other occasions, the 
inflammation seems to be confined to the lining membrane of the 
pelvis, which is found greatly enlarged and distended with pus, in- 
stances of which have fallen under my observation within the last 
few years; these were also treated as idiopathic fevers of the typhoid 
type. Cases are on record, where the suppuration has been so 
extensive, that the substance of the kidneys has been entirely de- 
stroyed. It is rare for the pus to escape into the cavity of the ab- 
domen, and equally rare for the abscess to point externally; but 
instances have been known where the matter has found its way into 
the colon, one case of which I have seen. It is said that gangrene 
occasionally ensues, but such a termination must be extremely rare; 
it is probable that the natural progress towards decay has been mis- 
taken for gangrene. When suppuration takes place, the more violent 
feelings subside; a throbbing sensation and a sense of weight are 
said to occur, with alternate chills, slight flushes of heat and profuse 
sweating. 

In chronic inflammation, induration of the kidney is produced, and 
sometimes it is completely disorganized. This diseased condition of 
the kidneys shall be fully illustrated in a subsequent part of this 
volume, in the chapter on Dropsy. 

Treahnent of inflammation of the kidneys. — Antiphlogistic 
means, such as are recommended for the cure of other inflamma- 
tions, are to be had recourse to. Copious venesection, repeated ac- 
cording to circumstances, and local bleeding, which is better etfected 
in this particular disease by cupping the loins than by applying 
leeches, are highly necessary. Fomentations, applied as hot as they 
CM be borne to the loins, are peculiarly soothing, fully more so than 
oeral warm bath, which, however, is not to be neglected ; gen- 
tle laxatives, particularly of the saline kind, are to be frequently 
repeated; linseed lea, or any other mucilaginous drink containing 
small proportions of the nitrate <>( potash, is to be taken, but diuretics 
ate not to be exhibited until the acute siage is subdued. Large in- 
jections of tepid water per annm are often found to produce tem- 
porary relief, and should therefore be frequently used. Rubefacients, 

particularly mustard plasters, applied to the lumbar region, are found 
beneficial, but are by no means to be used till towards the end of the 
acute stage. 

[ A MIT MI. NT III A. | 

[This malady has been familiar, for the past few years, by the 

name of Brighft di$etue, in compliment to Dr. Bright, who was 
the first to explain its pathological characters, It has also been called 
granular kidney, and albuminous nephritis. 



722 [ALBUMINURIA.] 

Its principal and distinctive feature is the presence of albumen in 
the urine, — an element which this secretion does not possess in its 
healthy state. 

With respect to the anatomical appearances in this affection, they 
are not easily defined, because they are so varied as to exhibit 
almost every pathological condition to which the kidney is incident. 
For example; on removing the proper investing membrane, the sur- 
face is seen to be of a pale or yellowish colour, or spotted or mot- 
tled with dark, chocolate-coloured stains. In other instances, the 
surface is rough or granulated. Sometimes there is atrophy, some- 
times hypertrophy of the whole gland ; but the former state is the 
result of the chronic affection, while the enlargement is attendant on 
the earlier periods of disease. If the kidney be laid open, all its 
parts are morbid in colour, consistence or proportion. The cor- 
tical substance is pale, or granulated or softened, according to cer- 
tain stages of the malady. The medullary portion suffers similar 
changes; and the whole gland is either pretematurally soft and 
flabby or the very reverse; and small cysts are occasionally associ- 
ated with these varied lesions. Dr. Christison, however, has defined 
the pathological character of albuminuria in the following brief de- 
scription;— a morbid deposit in the substance of the kidney, gene- 
rally in a granular form, occasioning atrophy of the proper renal 
structure, and indicated by more or less tendency to diminution of 
the solids of the urine, generally also by the presence of albumen, 
and frequently by the supervention of dropsical effusion. 

After all, this disease is remarkable for its variable characteristics; 
for it is now well established that the albuminous urine may coexist 
with, and be consequent to, genuine nephritis; that it may exist 
without nephritis, but complicated with dropsy; and again, albumi- 
nuria may exist when neither of the preceding diseases is present. 

Symptoms. — The access of this malady, in its acute form, is, for 
the most part, like that of acute nephritis, — fever, dull pains in the 
lumbar region, sometimes following the course of the spermatic cord 
to the testicle ; the urine is scanty, highly charged with albumen, 
and sometimes tinged or mixed with blood ; and these symptoms are 
sooner or later complicated with general dropsical effusion. Unless 
the disease is checked in its forming stage, it either terminates in 
coma and death, or puts on a chronic form. In the latter, the pains 
become dull and obscure, with anaemia, languor, indigestion and loss 
of flesh. The urine is either in excess or much diminished in quan- 
tity, presents the characteristic albuminurious quality and is, at the 
same time, deficient in urea. 

To detect albumen in the urine, nothing more is generally neces- 
sary than heating it to the boiling point, when the adventitious 
material is either at once gelatinized in the tube or vessel, or falls in 
flocculent masses to the bottom. Another method is first to treat 
the urine with heat alone, and then with nitric acid. Heat is, in 
general, a sufficient test where the albumen is in quantity; but 
where the proportion is small, the acid becomes necessary for its 
detection. 

Of all the secondary diseases, dropsy is the most frequent, and is 



[ALBUMINURIA.] 723 

not unfrequently the first serious indication of the renal disease. 
Nevertheless, even this condition is not essential. « Instances occur 
where the disease runs a long course without any dropsical effusion; 
it is, however, the most frequent of all the causes of dropsy. Many 
dropsies consequent upon scarlatina are of the same nature. So, 
also, are probably all those where the oedematous parts are elastic, 
and do not pit on pressure. So, too, are most, if not all cases attend- 
ed with diuresis, provided the urine be not saccharine."* Finally, 
by long continuance, the serous and mucous membranes become 
generally implicated, and diarrhoea, catarrh, internal dropsies, coma 
and apoplexy are among the train of consecutive affections. 

Treatment. — My own experience with respect to that form of 
renal disease which is essentially complicated with albuminous urine, 
is very limited. I have not even attempted to test the urine for the 
presence of albumen, though I have met with various instances in 
which its presence could be safely inferred from other symptoms. 
I have been accustomed to treat such cases with gratifying success 
with cathartics followed by alterative doses of blue pill, or nitro- 
muriatic acid, or by a solution of the bicarbonate of soda with 
digitalis, together with such a regimen as the nature of the case 
appeared to demand. 

An apartment of Guy's Hospital, London, has been appropriated 
to the exclusive use of this class of patients ; and Dr. Bright has 
therein fairly tested the relative advantage of various modes of 
treatment; nor do I know a better source for practical informa- 
tion than the following extract from his last report. " In the first 
steps and the more acute forms of disease, bleeding may be consi- 
dered the more important remedy ; but this is, of itself, wholly in- 
adequate to the cure, unless we purge freely, and at the same time 
call upon the skin to do its duty. Of all the measures for effecting 
this latter purpose, the strictest confinement to bed is the most effec- 
tual ; and without that, I do not believe that in this climate we have 
a chance of cure That preliminary, however, being adopted, anti- 
monials are probably the best diaphoretics; but the liquor ammoniac 
acetatis is likewise very useful; and a simple saline draught of 
citrate of potash or soda is, I believe, when diligently persisted in, of 
much avail j and the warm bath, in its various forms, may, in many 
cases, be brought to act most beneficially. 

"Amongst the purgatives, I shall only mention that elaterium and 
jalap, with the bitartrate of potash, appear to me the most effectual. 
When the disease has made further progress, and has become chronic, 
perhaps organic, I should still recommend the greatest attention to 
the full effects of purgation, to the state of the skin, and to protection 
from atmospheric changes; and I am more and more impressed with 
the probability that if complete change of climate were tried, great 
benefit might result. There are certain remedies whose actions in 
this disease rue less obvious than those to which I have referred ; 

but many of them probably set by affording a degree of stimulant or 
[• Chriattaoo, Library of Practical Medicine, m. p, 878. Per n <i<-t.-iii of the 

pathological ■ppeeMBOCf ns revealed on dissection, see llie chapter on Dropsy II thfl 
end of the present volume] 



T24 [ALBUMINURIA.] 

astringent action to the kidney ; of these I may mention the mineral 
acids as applicable in the declining stages of more acute attacks. The 
uva ursi, in its different preparations, in the chronic disease ; the 
pyrola nmbellata and the diosma crenata, where great irritability of 
the urinary organs exists : — a remedy which I have been led to adopt 
in many cases from the very favourable reports of Sir Benjamin 
Brodie ; nor have I been disappointed of some good effects, though 
I should employ with greater confidence, a long-continued course of 
conium, soda and uva ursi. One thing, however, must be kept in 
mind, — that whatever remedy is given to overcome a disease so 
chronic and confirmed, must be administered with exemplary pa- 
tience and perseverance."* 

To these measures Dr. Barlow, also of Guy's Hospital, adds tar- 
tar-emetic. He gives this medicine in nauseating doses in acute 
albuminuria ; but in smaller and merely diaphoretic portions in the 
chronic malady. 

It has occurred to me that very small and even minute doses of 
spirits of turpentine in combination or mixture with alkalies, and 
each dose followed by a very free draught of cold water, would 
operate favourably after the urgent symptoms of the acute stage have 
been reduced. The preparations of iodine, also, and especially the 
iodide of potassa, deserve a more extended trial than they have 
hitherto received.] 

[* Guy's Hospital Reports, in Braithwaite's Retrospect, Part I, page 55.] 



CHAPTER IV. 



HEMATURIA, OR DISCHARGE OF BLOOD FROM THE 
URINARY PASSAGES. 



It should be kept in remembrance, that when blood is passed by 
the urethra, it may proceed from one of three sources, viz.: the kid- 
neys, bladder or urethra itself. 

When the discharge comes from the kidneys, the patient complains 
of a sense of fulness, weight and dull pain in the loins, accompanied 
with some degree of faintncss and nausea. When from the bladder, 
a sense of heat and fulness is felt in the hypogastric region, involun- 
tary bearing down, and urgent desire to make water. But active 
haemorrhage for the most part takes place from the urethra only, and 
is generally the consequence of the use of the bongie in cases of 
stricture. If such a discharge take place from the kidneys or blad- 
der, it will, in general, be found to depend on external injury. A few 
months ago I attended a patient who discharged, for the space of a 
week, a large quantity of florid blood daily; sometimes it flowed 
from him when in bed, at times when affected with priapism, at 
others when making water, so that it was occasionally pure blood, 
and at other times blood mixed with urine. The complaint seemed 
to have been produced by a long train of sacrifices at the shrine of 
Venus. 

A discharge of blood from the urethra sometimes takes place in 
the course of purpura hemorrhagica, ;is has been already mentioned. 
A discharge of blood frequently occurs where there is a stone in the 
bladder, and I have seen it produced by the internal use of cantha- 
rides. 

Treatment of hematuria. — It is necessary to ascertain whether 
or not the discharge be confined to the urethra, respecting which the 
history of the case will generally inform us. If there be considera- 
ble pain in the region of the bladder, more particularly if the blad- 
der he much distended, it will he sometimes found serviceable to 
introduce as large a sil vet catheter as can he passed. 

In the treatment of active hemorrhage from any or^an, if the 
pulse he full, and if there be marks of lost balance of the circulation, 
the beneficial effects of opening a eein in the arm have been long 

Well known. It is to he i .•com mei ii |c d in (Ins case, also, if the pulse 

he strong, and more particularly, if much local pain exist ■ but in the 
noticed above, I depended entirely on (he use of the acetate of 

lead in considerable doses. The patient was kept nine days under 
84 



738 HEMATURIA. 

the influence of this medicine. During three days he took 5 grains 
of that preparation, combined with a small proportion of opium 
three times a-day ; and for the remaining six days the quantity was 
increased to 10 grains thrice a day. I never had greater reason to 
be satisfied with the action of any medicine ; the only unpleasant 
effect it occasioned was constipation. 

Gentle laxatives and cold water enemata are to be employed in 
all cases of hematuria. If there be much constitutional irritation, 
opiates will be found serviceable, and their use cannot be dispensed 
with if the patient have lost such a large quantity of blood as to pro- 
duce a great and permanent impression upon the system. In cases 
accompanied by vomiting, which is a frequent attendant on excess- 
ive haemorrhages, opium should be given, combined with calomel. 
The external application of cold may do good in slight cases, if the 
person be able to sit over a tub or on a bidet, but the application 
should not be persisted in too long : and it is bad practice, particularly 
in severe cases, to keep a person's garments constantly wet. It does 
mischief, by abstracting heat from the body when it cannot be spared 
as well as by driving the blood from the surface, and keeping up a 
tendency to irregular distribution. 

The best plan of stopping the discharge of blood which has its 
source in the urethra, is by pressing that canal in different places 
between the finger and thumb until the haemorrhage is commanded, 
and afterwards to apply a large compress to the part by means of a 
T bandage, so as to keep up the necessary degree of pressure. 



CHAPTER V. 



DIABETES 



Br this term is meant a superabundant secretion of urine, con- 
taining a large proportion of saccharine matter ; sometimes, how- 
ever, the quality of sweetness is wanting. To the former, authors 
have applied the term Diabetes mellitus, in contradistinction to the 
other, which has been termed Diabetes insipidus. 

It has been recommended, however, that the term "diabetes" 
should be restricted to those instances in which the urine is saccha- 
rine, and I shall follow this suggestion. 

It is my invariable plan, both in lecturing and writing, to make 
marked distinctions between those diseases with which experience 
and actual observation have made me acquainted, and those respect- 
ing which I know little, and that little from the experience and writ- 
ings of others. In commencing the consideration of this intractable, 
but rare disease, it is my duty to confess that I know nothing what- 
ever respecting its nature and seat. Since writing the second edition 
of this work, three cases of diabetes have fallen under my care. 

Notwithstanding the attention which this singular disease has 
attracted, since the celebrated Willis drew the attention of the pro- 
fession to its investigation in 16S4, and although men of powerful 
minds, assiduous habits and great practical experience have been 
drawn into discussions respecting it, doubts to this day exist, not 
only as to the Baton of the disease, but also the organ principally 
and primarily allected. True it is, that, by the assistance of morbid 
anatomical investigations, we have found out some diseased appear- 
ance in the urinary and digestive apparatus; and that, by the aid 
of chemistry, the morbid character of the urine and its component 
parts have been discovered ; yet it has never been explained, in a 
satisfactory manner, whether the diseased state of parts and the 
morbid state of urine stand in relation of cause or effect. Still 
greater mystery hangs over the subject, when it is known that the 
kidneys have been found perfectly sound in structure and un- 
changed in appearance. Were we to be led, in forming an opinion 
as to the primary seat of the disease, by the accounts which a ma- 
jority of patients give of their first symptoms, we should certainly 
feel disposed to fix upon tin: stomach, and not upon the kidneys, as 
the proper seat of the affection ; but then the same may be said of 
almost all the disorders of the urinary system. 



740 DIABETES. 

Symptoms of diabetes. — "Diabetes is attended (says Dr. Latham,* 
p. 1,) for the most part with a very voracious appetite, and with an 
insatiable thirst ; with a dry harsh skin, and a clammy, not parched, 
but sometimes reddish tongue ; and with a frequent excretion of very 
white saliva, not inspissated, but yet scarcely fluid. As the disease 
proceeds, it is accompanied often with a hay-like scent or odour, 
issuing from the body, with a similar sort of halitus exhaling from 
the lungs, and with a state of mind dubious and forgetful: the pa- 
tient being dissatisfied, fretful and distrusting, ever anxious, indeed, 
for relief, but wavering and unsteady in the means advised for the 
purpose of procuring it." Diabetes comes on very insidiously ; the 
patient complains of unusual lassitude, and a tendency to perspire 
on every slight exertion ; and although the appetite is much greater 
than natural, the digestion is seldom good, there being uneasiness in 
the stomach after eating, flatulent distension, heartburn and an 
irregular state of bowels. Pain is sometimes complained of in the 
region of the loins ; occasionally it is very violent, and there is always 
a weakness referred to that part of the body. As the disease goes on 
towards a fatal termination, there is a feeling of exhaustion ; diffi- 
culty of breathing, together with dropsical infiltration into the lower 
extremities, and general rapid emaciation take place ; the pulse, 
which is not usually much affected at the commencement, becomes 
quick and weak. 

The urine is of a straw colour, having a peculiar smell, which 
struck me to resemble whey that had been allowed to stand till it 
became somewhat sour ; the quantity passed in twenty-four hours 
has been stated as high as two hundred pounds, (Roche and Sanson, 
vol. 2, p. 121;) but keeping extraordinary cases entirely out of the 
question, it is certainly most remarkable, that the urine, in confirmed 
cases of diabetes, always exceeds the weight of both solid and fluid 
ingesta. The secretion may be stated at between ten and twenty 
pounds daily, which obliges the patient to evacuate the bladder very 
frequently, and disturbs him four or five times during the night, 
which, by breaking the rest, assists in destroying his health. 

The quantity of sugar in diabetic urine is very various even in the 
same individual; as much as one ounce has been extracted from each 
pound of urine, sometimes even more, but the average quantity is not 
nearly so great. A considerable proportion of saccharine matter has 
been collected by evaporation, when it could not be detected by the 
taste; but we are told that the quantity may always be estimated by 
the specific gravity of the urine. According to the French, the most 
delicate agents scarcely indicate the presence of the lithic and phos- 
phoric acids, the phosphates of soda, lime, or the ammoniaco-mag- 
nesian, which are always present in the healthy state of this fluid. 

Diabetes has been generally fatal; its duration has been variously 
stated from five or six weeks to many months, and even to several 
years. 

* Dr. Lalham has investigated and criticised ancient and modern opinions on this 
disease, with the greatest ability, in a work entitled "Facts and Opinions concerning 
Diabetes," 1811, to which I can, with the greatest confidence, refer my readers for 
much valuable information. 






DIABETES. 741 

Appearances on dissection in diabetes. — I have seen two dissec- 
tions, in which the kidneys, to all appearance, were in a healthy state, 
and in which the lungs, and the mucous membrane of the stomach, 
and of a great portion of the bowels, were diseased, the former being 
tuberculated, and the latter vascular, the vessels gorged with dark 
blood, and the mucous membrane itself soft and pulpy. It has been 
stated, however, by others, that the only organ in which any morbid 
structure has been clearly ascertained, is the kidney. Mr. Cruick- 
shank, in his work on the lacteals and lymphatics, affirms that the 
arteries of the kidneys are generally enlarged in this disease, par- 
ticularly those of the cryptae, or minute glands which secrete the 
urine. In a case which occurred to Dr. Baillie, " the veins upon the 
surface were much fuller of blood than usual, putting on an arbor- 
escent appearance. When the substance of both kidneys was cut 
into, it was observed to be everywhere much more crowded with 
blood-vessels than in a natural state, so as in some parts to approach 
to the appearance of inflammation. Both kidneys had the same 
degree of" firmness to the touch as when healthy; but I think were 
hardly so firm as kidneys usually are, the vessels of which are so 
much filled with blood. It is difficult to speak very accurately about 
nice differences in degrees of sensation, unless they can be brought 
into immediate comparison. A very small quantity of a whitish 
fluid, a good deal resembling pus, was squeezed out from one or two 
infundibula in both kidneys, but there was no appearance of ulcera- 
tion in either." This description of the condition of the kidneys 
would most exactly represent that seen in many cases of cholera, in 
which the secreting power of the kidneys had been destroyed for days. 

Causes of diabetes. — Diabetes attacks men more frequently than 
women, but seldom earlier than in middle age. I believe it has been 
found that no rank of society is exempt from its invasion ; and it does 
not appear that any kind of occupation predisposes to it more than 
another. It is also said to be unknown in warm climates, although 
I have heard of an instance which occurred in the West Indies. 
There can be no doubt, however, that it is more frequently seen in 
cold, humid climates; therefore it is said to be more common in Hol- 
land and in England than elsewhere; but if this were the case, not 
only with respect to climate, but other exciting causes generally 
mentioned, such as "chagrin, vegetable diet, intemperance and other 
excesses, suppressed eruptions, atonic gout, diseases of the liver, 
lungs, &.c, and ill-conditioned ulcers," we should see the disease 
every day, whereas it is avowedly rare. A curious fact may be men- 
tioned, which was first stated by Chesselden, and is mentioned at 
page 1 39 of his Anatomy, viz.: that sweet urine is sometimes secreted 
in cases of chronic carbuncle. 

Pathology qf diabetes. — From all the facts hitherto collected, very 
different pathological conclusions have been drawn, and supported 
by men of acknowledged celebrity. 

1. It has been supposed that the disease depends upon a morbid 
condition of the stomach, or other viscera connected with the assimi- 
lation of the food and the process of chylification. 

2. On the imperfect animalization of the blood. 

62* 



742 DIABETES. 

3. Upon the retrogade action of the lymphatic vessels. 

4. Upon a morbid condition of the kidneys themselves. 

Being so imperfectly acquainted with the disease, I cannot do 
better than condense the opinions which have been collected by Dr. 
Mason Good in his " Study of Medicine." 

1. It seems to be a most extensively received hypothesis, that dia- 
betes depends upon a diseased action in the stomach, &c. Dr. Mead, 
observing that the disease frequently occurred in those who had 
been accustomed to live intemperately, and who were chiefly addict- 
ed to the use of spirits, attributed it to affections of the liver; which 
opinion was very generally received in his time. 

Dr. Rollo, formerly surgeon-general of the artillery, was among 
the first who referred the disease to the stomach; he believed that it 
consists in an increased action and secretion in this organ, with a 
vitiation of the gastric juice, and probably a too active state of the 
lacteal absorbents; while the kidneys and other parts of the system, 
as the brain and skin, are only affected secondarily. 

He supposed that the blood is imperfectly formed, and deficient in 
its saline principles, which are converted into saccharine matter by 
the chylopoietic and assistant chylopoietic viscera; but a fatal objec- 
tion to this part of the hypothesis is, that it has been found, by expe- 
riments performed by Wollaston and Marcet, that blood taken from 
diuretic patients before it has reached the kidneys, contains its proper 
salts, and shows no vestige of sugar. There can be no doubt, how- 
ever, that the first symptoms of which patients complain are referred 
to the stomach, and that this organ has been found with diseased 
appearances after death. A stomach was lately presented to me, 
snowing this fact in a remarkable degree ; there is a drawing of its 
appearances when recent in my possession, and the stomach itself is 
dried and preserved, and still shows these appearances. 

2. With respect to the second opinion, that diabetes depends upon 
an imperfect animalization of the blood, the hypothesis originated 
with Willis immediately after he detected the existence of sugar in 
diabetic urine, since which it has been subscribed to by many dis- 
tinguished pathologists, among whom we find the name of Syden- 
ham. The chief support upon which this opinion is founded, is the 
appearance of the blood itself, which is dark-coloured, has what has 
been termed a dissolved appearance, looks like treacle, and when al- 
lowed to stand after being drawn from the system does not separate 
much, if any, serum ; but, on the other hand, the experiments of Wol- 
laston, Marcet and others, which go to show that the blood con- 
tains its proper salts and no vestige of sugar, have proved equally 
fatal to this as to the last hypothesis. 

The theory, however, is advocated by Dr. Latham, who believes 
the action of the stomach, as well as of the kidneys, to be healthy, 
and considers the excessive appetite to be a " natural sensation call- 
ing into its full exercise that organ through which the constant waste 
of the body must be directly supplied, and without which the patient 
must soon inevitably perish," (p. 330.) He endeavours, also, to show- 
that the elements of sugar may exist in the blood, although in sub- 
stance it is not discoverable, being "so weakly and loosely oxygen- 



DIABETES. 743 

ated, as to be again readily evolved by the secretory action of the 
kidneys, not from any fault in the kidneys themselves, but from the 
regular and natural exercise of their functions iu separating from the 
imperfect blood such matters as are not properly combined with it." 
(P. 97.) 

3. The third opinion, that diabetes depends upon a retrogade ac- 
tion of the lymphatic vessels, first originated with the son of the dis- 
tinguished author of the Zoonomia, by whom it was afterwards very 
keenly supported. According to his view, the saccharine matter is 
formed in the digestive organs, and then carried by a retrogade mo- 
tion of the lymphatics to the kidneys. In reference to this subject, 
Mr. Cruickshank asks the following query (at p. 69.) " Why should 
the chyle tlow retrogade into the lymphatics of the kidney, and not 
into the lacteals themselves? and why are not the faeces fraught with 
a similar fluid, as well as the urine?" — These are unanswerable 
queries, and are fatal to this hypothesis. 

4. Diabetes has been referred to a morbid condition of the kidneys 
themselves. This opinion was entertained by the Greek writers, 
who supposed the kidneys were in a state of great relaxation, debi- 
lity and irritability. A considerable number of the profession have 
adopted the opinion that the kidneys are really the primary seat of 
the disease ; and the majority of these ascribe it to some degree of 
inflammation, although by some it is attributed to spasm. Cullen 
adopted this last notion so completely, that he placed diabetes in his 
class neurosis, and order spasmi, immediately before hysteria and 
hydrophobia; for doing which he has given, as Dr. Mason Good 
observes, a most unsatisfactory reason. Many suppose, then, that 
there is no necessity to look further than the kidneys for the seat of 
the disease, and that its nature is to be attributed to a morbid irri- 
tation connected with an inflammatory action of a peculiar kind; 
therefore it is believed by them to be a very simple and uncompli- 
cated disease. Dr. Mason Good is a strenuous supporter of this 
view; and the following are the most forcible of his arguments. It 
is well known that the secretion of the kidneys is capable of being 
incr ea sed by various BgentS. He believes that a strong analogy 
exists between dropsy ami diabetes; and as a large quantity of fluid 
is thrown out in the former, from the excited secretory vessels, there 
riu be little difficulty in believing, that from a primary morbid ex- 
citement in the kidneys themselves, they may eliminate as much 
urine as is ever passed by diabetic patients. He also considers the 
analogy between dropsy and diabetes to be strongly supported by 
the existence of similar constitutional elects; the whole body, drained 
of the. thinner parts of the blood, is weakened and emaciated, and 
most of its functions are cither performed very slowly, or are alto- 
gether retarded ; but be believes, with Dr. Latham, that the excessive 
appetite, so frequently observed m diabetes, is a direct proof of the 
Soundness "I the function! <>| the stomach, although they arc inordi- 
nately excited to supply the general wants of the system. 

The supposition that the remarkable change m the composition of 
the urine takes place in the blood, appears to Dr. Good to have arisen 
from the diliiculty of imagining how the kidneys, the natural function 



744 DIABETES. 

of which is to secrete an alkali and an animal acid, should have their 
action so completely perverted as to secrete saccharine matter; but 
he states that, under particular circumstances, many organs exhibit 
a disposition to throw out sugar, both in health and in disease, what- 
ever may be their proper secretion; and this circumstance occurs 
under the use of an animal, as well as of a vegetable diet. This 
human milk is peculiarly sweet ; saliva and pus sometimes exhibit 
the property of sweetness, and the sweat, in some fevers, smells of 
oxalic acid. 

It is difficult to form any pathological opinions from the discordant 
facts which have been recorded respecting this disease, having had 
no opportunity of investigating the matter with the advantage of a 
full knowledge of what had been already done by others. Guarding 
myself, however, against the effects of the special pleading of many 
writers on this subject, I cannot help coming to the conclusion that 
the truth lies between the two extremes — that pathologists have 
been too anxious to attribute the disease to one particular organ — 
and that those who object to the view that the kidneys are the seat 
of the disease, have probably expected to find some very uncommon 
disorganization or vascular turgescence. I am inclined to believe 
that diabetes is a functional affection of the kidneys, produced by 
a combination of circumstances which rarely exist, otherwise the 
disease would be of far more frequent occurrence ; and that we may 
look for that combination to the functions of the stomach and other 
organs connected with digestion, and also to those of the lungs; and, 
if this be admitted, there can be no difficulty in perceiving that the 
constitution of the blood must suffer some alteration, and that the 
functions of the nervous system must likewise be considerably em- 
barrassed. 

Treatment of diabetes. — The different views entertained by me- 
dical men concerning the pathology of the disease, have led to various 
and very opposite modes of treatment. Willis, with the view of 
giving firmness and coagulability to the blood, and of invigorating 
the system, recommended a cooling diet, the albumen of eggs, traga- 
canth and gum arabic, to which he added rhubarb, cinnamon, lime- 
water, cordials and opiates, if required. 

Sydenham carried the invigorating plan still further : he prescribed 
animal food of easy digestion, with an allowance of wine, and absti- 
nence from vegetable substances. 

Frank has great faith in the application of a blister to the sacrum, 
and the internal exhibition of assafoetida, valerian, &c. 

Rollo, with the expectation of preventing the formation of sugar 
and favouring that of the animal salts, enforces a total abstinence 
from vegetable diet, a very liberal allowance of animal food, and the 
use of hepatized ammonia, together with occasional narcotics ; and, 
under the idea that the stomach alone is at fault, he recommends an 
occasional emetic. 

Dr. Latham, with the exception of the use of emetics, to which he 
objects, subscribes to the treatment recommended by Rollo, although 
he entertains different pathological opinions. He substitutes phos- 



DIABETES. 745 

phoric acid for the ammonia, with a view of supplying the deficiency 
of the animal salts, particularly the earthy phosphates. 

Those who believe the kidneys to be irritated, if not inflamed, 
recommend general and local bleeding ; and to the late Dr. Watt, 
of Glasgow, belongs the merit of reviving the practice, which had 
altogether fallen into disuse. He trusted almost exclusively to bleed- 
ing, and, it would appear, with considerable success. Dr. Satterley 
lias since followed this plan with even greater success than Dr. Watt, 
and an account of his cases is to be found in the 5th vol. of the Me- 
dical Transactions. The subject of Dr. Satterley's first case was a 
man 32 years of age, previously debilitated by long-continued ill 
health. He was admitted into Middlesex Hospital on the 18th of 
February, 1809, labouring under well-marked symptoms of diabetes, 
with a small, quick and hard pulse, and excessive thirst. On the 
19th, 14 oz. of blood were taken from him ; he was ordered to have 
animal food and a moderate allowance of liquids. On the 20th, 18 
oz. more were abstracted; 20 oz. on the 23d,29oz. on the 25th, and 
18 oz. each day on the 28lh, the 3d and 11th March, making an 
amount of 126 oz. in the course of 20 days. 

Along with this active treatment were conjoined restriction to ani- 
mal food for diet, lime-water and alum whey for drink, occasional 
purgatives, and very frequently, during the whole course of the dis- 
ease, one grain of calomel, and a dose of Dover's powder at bed- 
time. 

The diminution effected by the bleedings on the quantity of urine 
passed in 24 hours, is as follows:— After the first bleeding, it was 
reduced from 16 quarts to 1 1 ; the second to 6; — the fourth to 
between 5 and 7;— the fifth to between 5 and 6;— after the sixth, 
to k\ss than 5 ; and after the seventh, to about 3, sometimes 2 quarts. 

The excessive thirst gradually left him, and his health and strength 
improved. He remained, however, in the hospital for some time, 
in consequence of an attack of pneumonic disease, for which he 
required to be Med once or twice; but was ultimately discharged 
cared, and he hid DO return of the diabetes several years afterwards. 

Other instances are recorded by Dr. Satterley, in which the same 
plan was pursued, with the like success; but some practitioners who 
entertain similar opinions concerning the nature and sent of the dis- 
. endeavour to allay the local and general irritation, by means 
of the frequent exhibition of narcotic medicines, such as opium, 
Without having recourse to venesection. 

The following is a summary of the practical conclusions at which 
Dr. Mason Good arrives. Diabetes attacks different ages, constitu- 
tions and habits, consequently it requires different modes of treat- 
ment, it is situated in the kidneys, with the state of which other 
organs sympathize. Animal food diminishes the tendency to saccha- 
rine secretion. Opium, in some instances, allays the irritation, and 
at length subdues it; but, in other cases, a free use of the lancet 
Is more speedily. Colchicum has sometimes proved 
oi more advantage than opium. Free depletion cannot be had re- 
e to in all cases, as the disease often attacks the old, and those 

who have been previously debilitated ; it is only admissible m C 



746 DIABETES. 

where the constitution and digestive organs are unimpaired. Tonics 
and astringents, together with the mineral acids, which allay the dis- 
tressing thirst, are often found serviceable, as are lime-water, alum- 
whey and mineral waters. 

I have only to add, that, from the effects of acetate of lead in re- 
straining active haemorrhage and other discharges, it may be found 
useful in diabetes, and is therefore worthy of trial. It was bene- 
ficial in the three cases to which I have alluded. The last accounts 
received from one of the patients stated that he had been quite well 
for several months. 



CHAPTER VI. 
SYPHILIS. 



Much learned controversy has taken place respecting the origin of 
syphilis, but, after all, it is more interesting to naturalists and histo- 
rians than to practical men. As my object is to offer the result of 
my labours to the profession in as small a space as possible, the 
history of the origin of this disease is inadmissible with my plan, 
particularly as many points of immense practical importance have 
been abridged, at the risk of producing obscurity which more ample 
illustration would prevent. 

Syphilis appears under various forms, and is supposed to be pro- 
duced by a peculiar virus applied to the parts of generation during 
impure connection. It occurs generally from the third to the seventh 
day after the application of the syphilitic matter. Some allege that 
it may take place later. The symptoms produced by the syphilitic 
virus have been divided into local and constitutional, and also into 
primary and secondary; 1 shall restrict the term constitutional to the 
febrile symptoms, which are sometimes produced when the local in- 
flammation is intense and deep-seated, and shall apply that of second- 
ary to all other constitutional effects, such as sore throat, cutaneous 
eruption, nodes, &c. 

Local symptoms of syphilis. — When a sore is situated on the 
parts of generation, the fruit of impure connection, it is termed a 
chancre, and may be on the glans, the prepuce, at the angle formed 
by the junction of the two former, at the fraenum, at the orifice of 
the urethra, or on the body of the penis. In the female, chancres are 
generally situated about the labia, nymphce, clitoris and meatus uri- 
narius. 

The first appearance of a chancre is generally announced by some 
degree of itching, and, upon examination, something like a pimple is 
observed, having an inflamed base, which feels hard to the touch ; it 
soon shows an elevated point, from a small opening in which a lim- 

f)id fluid is discharged, and from which ulceration extends more or 
ess rapidly. Some ulcers are superficial, with hardened bases; others 
are raised and spongy; while some extend very deep, and are sur- 
rounded by hard, ragged edges. I'lcers on the prepuce are generally 
raisod, and are larger than those situated on the glans, which are 
more frequently excavated than those on the prepuce. Chancres also 
originate from cracks or fissures, which so frequently take place on 
the prepuce, at which parts ulceration subsequently happens; or a 



748 SYPHILIS. 

pimple or vesicle is formed, from the apex of which the ulceration 
extends. There is another appearance frequently observed, viz.: a 
large excoriation resembling the sores which take place behind the 
ears of children, and which affects not only the glans, but the lining 
membrane of the prepuce, and produces considerable inflammation, 
profuse discharge, and often swelling of the prepuce itself, preventing 
its retraction, and thus forming the state called phymosis. 

The degree of inflammation which accompanies these varieties of 
chancre, differs very much, sometimes being very slight; at others, 
so severe and extensive as to terminate in sloughing of considerable 
portions of the penis. This, there is every reason to believe, depends 
more upon the state of the constitution of the patient than upon the 
virulence of the matter applied. The degree of pain also varies, some- 
times being exceedingly severe, at others scarcely complained of, and 
seems to depend more upon the depth and activity of the inflamma- 
tion than upon the extent of surface involved, or the swelling of the 
part. 

In certain states of the constitution, an eruption of vesicles appears 
on various parts of the body, and not uncommonly on the penis, 
particularly at the prepuce, and has therefore been called herpes prx- 
putialis ; and I agree with Bateman and others, that this affection 
sometimes bears such a close resemblance to chancre as to be liable 
to be mistaken for it; and Mr. Plumbe states, (at page 310.) that the 
mistake "is by no means an occurrence to be apprehended where 
much professional knowledge exists on the part of the surgeon or 
physician;" — and further, that, "at the present day, no man who 
knows ivhat he ought to know of the science could possibly commit 
such a blunder;" yet it is my duty to confess that I fear I have often 
committed such a blunder, and am inclined to believe that there are 
few men in practice who have not done the same. Sores on the 
labia of children produced hy acrid discharge are frequently seen, 
which closely resemble the description of the true Huntenan chancre, 
and I have seen the same appearances in the mucous membrane of 
the bowels. From observation, I am inclined to believe, that for one 
instance of the true Hunterian chancre, other sores are met with fifty 
times. 

The glands in the groin frequently inflame and suppurate during 
the existence of ulcers on the external parts, but it is comparatively 
rare that this occurs on both sides. It does not appear that buboes 
take place in an average of cases more frequently than once in 
twenty. On some occasions they suppurate quickly, on others very 
slowly, and sometimes attain a considerable size, and continue indu- 
rated for many months before suppuration takes place, if it take 
place at all. 

Secondary symptoms of syphilis. — The most frequent of these is 
an ulcerated state of the fauces, pharynx and Schneiderian mem- 
brane. The disease, in bad constitutions, and under improper treat- 
ment, may destroy considerable portions of the soft palate, uvula 
and tonsils; the ulceration sometimes extends to the epiglottis, and 
even to the larynx, so as to destroy its cartilages, and in process of 
time into the nose, affecting and destroying its bones. 



CHAPTER II. 

CALCULUS IN THE KIDNEYS— BLADDER— AND OTHER 
PARTS OF THE URINARY PASSAGES. 



The urine is one of the most complicated fluids secreted by ani- 
mals; it is composed of acids, alkalies, calcareous earth and other 
substances hereafter to be noticed. 

The substances hitherto discovered in urinary calculi are I i t hie, 
sometimes called uric acid— phosphate of lime— ammoniaco-mag- 
nesian phosphate — oxalate of lime— cystic oxide, with a variable 
proportion of animal matter cementing their ingredients. Accord- 
ing to the best authorities, it would appear that these substances sel- 
dom exist singly, yet some of them generally prevail in a sufficient 
degree to impart to each stone a peculiar character. Dr. Marcet has 
given the following classification: 

1. Lithic calculus; — 2. bone-earth calculus, principally consisting 
of phosphate of lime ;— 3. the ammoniaco-magnesian phosphate ;— 4. 
the fusible calculus, consisting of a mixture of the two former; — 5. 
the mulberry calculus, or oxalate of lime; — 6. the cystic calculus, 
consisting of the substance called by Dr. Wollaston cystic oxide ; — 
7. the alternating calculus, or concretion, consisting of two or more 
different species arranged in alternate layers; — 8. the compound 
calculus, the ingredients of which are so intimately mixed, as not to 
be separable without chemical analysis; — 9. calculus of the prostate 
gland. 

1. Lit hie calculus. —So called from the preponderance of lithic 
acid, which substance was first discovered by Scheelc. This is a 
hard, inodorous concretion of a brownish or fawn colour, sparingly 
soluble in water, but easily dissolved by solutions of either of the 
fixed alkalies. It is also soluble in nitric acid. When exposed to 
the action of the blow-pipe, it blackens, emits a peculiar animal smell, 
and gradually evaporates, leaving a little white alkaline ash. 

2. The bone-earth calculus, principally consisting of phosphate 
of lime. — The existence of a urinary concretion, consisting entirely 
hi phosphate of lime, was first pointed out by Dr. Wollaston, who 

the following description of its appearance: "lis surface is 
generally of a pale brown, and BO smooth as to appear polished; 
when sawed through, it is found very regularly laminated, and the 
laminae in general adhere so slightly to each other, as to separate 
with ease into concentric crusts." When powdered, this calculus is 
til 



726 URINARY CALCULI. 

very soluble either in the muriatic or nitric acids. Under the action 
of the blow-pipe it first blackens, but soon becomes perfectly white. 
Dr. Marcet thinks that calculi entirely composed of pure phos- 
phate of lime are very rare. 

3. The triple calculus, or ammoniaco-magnesian phosphate. — 
Dr. Wollaston also discovered this triple salt as a constituent of urin- 
ary concretions, although calculous masses consisting solely of this 
substance are, perhaps, never met with. Calculi in which the am- 
moniaco-magnesian phosphate prevails, are generally whiter and 
less compact than those of the former class. An ammoniacal smell 
is emitted under the blow-pipe, the fragment diminishes in size, and, 
if the heat be strongly urged, an imperfect fusion takes place, leaving 
a phosphate of magnesia. 

4. Fusible calculus. — With the exception of the lithic, this kind 
of calculus occurs more frequently than any of the others. It is also 
in general whiter, and more friable, sometimes resembling a mass of 
chalk. It likewise appears in the form of a spongy and very friable 
whitish mass, without a laminated structure. 

5. The mulberry calculus, or oxalate of lime. — It was Dr. 
Wollaston who first discovered this substance in urinary calculi. 
Although named mulberry from its external resemblance to that 
fruit, yet we are assured by Dr. Marcet, that a number of calculi of 
this class occur, which, far from having the mulberry appearance, 
are remarkably smooth and pale-coloured ; and it is conjectured 
that the dark colour of the tuberculated calculi may arise from im- 
bibition of blood. 

6. The cystic oxide calculus. — This calculus was first discovered 
by Dr. Wollaston, and resembles more nearly that of the triple phos- 
phate of magnesia than any other sort; but is more compact, has no 
distinct laminae, and appears as one mass confusedly crystallized; it 
has a yellowish semi-transparency, and a peculiar glistening lustre, 
like that of a body having a high refractive density. The solvents 
of the cystis oxide are too numerous to be particularized here ; but it 
may be mentioned that it is not soluble in water, alcohol, acetic, tar- 
taric and citric acids, or saturated carbonate of ammonia. 

7. The compound calculus in distinct layers. — Calculi of this 
description are frequently seen in practice, and show lithic strata 
alternating with layers of oxalate of lime, or with its phosphate. Dr. 
Marcet has given a representation of a calculus, in which" lithic acid 
forms the nucleus, pure phosphate of lime being next to this, and so 
on, the fusible crust at last enveloping the whole concretion. 

8. Compound calculus with the ingredients intimately mixed. — 
This kind is comparatively rare; but Dr. Marcet states, it may be 
sometimes recognized by its more or less irregular figure, and less 
determined colour — by being less distinctly, if at all stratified— and 
by often possessing a considerable hardness. When exposed to ana- 
lytical processes, confused results are obtained, which soon proclaim 
its compound nature. 

9. Calculus formed in the prostate gland.— Calculi formed in 
this situation often give rise to symptoms which are mistaken for the 
effects of stone in the bladder. According to Dr. Wollaston, they all 



CALCULUS IN THE KIDNEY. 727 

consist of phosphate of lime, not distinctly stratified, and are tinged 
with the secretion of the prostate gland ; the salt is in the neutral state, 
without a redundance of calcareous earth as in bones. Their exter- 
nal appearance is similar to that of the lithic calculi; but Dr. Marcet 
has shown of how much consequence it is, in a practical point of 
view, to be able to detect the difference. For full information upon 
these points, and upon all others connected with the formation of 
urinary calculi, I must refer the reader to Dr. Marcet's excellent work 
on calculous disorders, published in 1S19. 

Besides these, Dr. Marcet describes two other kinds of calculi, the 
names of which I shall only mention: — 1st. The Xanthic oxide, which 
makes an approach to the cystic calculus, but gives a bright lemon 
residuum on evaporating its nitric solution, which is not yielded by the 
cystic calculus. 2d. Fibrinous calculus, so called from its possessing 
properties similar to those of the flbrine of the blood, and supposed to 
be formed by a deposit from the blood. 



CALCULUS IN THE KIDNEY. 

Symptoms.— Long-continued obtuse pain is felt in the lumbar re- 
gion, shooting downwards, and producing a numbness in the thigh 
of the affected side, with painful retraction of the testicle, increased 
on taking exercise. There is a frequent desire to make water, which 
is discharged in small quantity at a time, and generally of a deep-red 
colour, often depositing a brick-coloured sandy sediment. A great 
many cases have been recorded where calculi of considerable size 
have been lodged in the kidney, without producing much inconveni- 
ence to the patient; a remarkable instance of which is given by Dr. 
Marcet. The state of parts is well represented in his first plate, 
which shows the pelvis of a diseased kidney much enlarged, and 
distended by a number of calculi closely pressed against each other; 
other calculi are seen in the: enlarged infundibula. The patient died 
under Dr. Marcet's care at Guy's Hospital, of hydrotborax, ''without 
any symptom having occurred which could lead me to suppose that 
there was any disease in the urinary organs." There is also a remark- 
able preparation in my museum, taken from the body of a woman 
who died of what w.-is considered te be typhus fever; the kidney 

was enlarged, of scirrhous hardness; the ureter was destroyed, and a 
large calculous mass was found in the substance of the kidney. Had 
the woman lived long enough, it would have been discharged by 
stool. It was m the left kidney, to Which the descending colon was 
strongly attached; several ulcerations are to be Been through the in- 
testinal tube, communicating with the calculus. The woman had 
been long slightly ailing, and there can be no doubt that the febrile 
symptoms which occasioned hei death were produced by local irri- 
tation-, she bad been tot some time afiectedwith diarrhosa, and occa- 
|y the Btools were bloody. 

Vv*e are U>ld by Dr. Manet, tbat when a calculus is lodged in the 

kidney, a suppuration and gradual wasting of the organ lake | 

in Which ciroumstani rally accompanied by long- 



728 CALCULUS IN THE KIDNEY. 

continued pain in the lumbar region, and by a discharge of purulent 
nrine, not unfreqnently attended by copious haemorrhage. 

Some years ago, I extracted a stone, weighing one ounce and 35 
grains, from the bladder of a female, by dilating the urethra, which 
was effected by sponge-tents. The patient died some time after- 
wards from apoplexy, and on dissection, the arteries of the body 
were found generally ossified; one kidney was in a state of atrophy, 
its emulgent artery being very much diminished in size at its origin 
by an ossific deposition. The other kidney was considerably en- 
larged, although its structure appeared to be sound; and another 
calculus, the size of a small bean, was found in the pelvis, about to 
enter the ureter, which was much dilated through its whole course, 
and appeared as if it had formerly given passage to the nucleus of 
the large stone which had been previously extracted. The symp- 
toms under which this woman had laboured for a number of years 
were not of so marked a character as to attract the attention of a 
great number of medical men in Edinburgh, who had seen her at 
different times. This, perhaps, may be fairly attributed to the com- 
bination of symptoms produced by the general disease in the coats 
of the arteries. 

It would appear probable, that acute pain and great suffering are 
produced more frequently when a calculus is in its passage from the 
kidney through the ureter than at any other time ; and I believe it is 
generally remarked, during the passage of a calculus, that the pain is 
excruciating, not only in the loins, but also in the testicle from its re- 
traction ; yet the pulse remains, for the most part, unaffected, which 
is a phenomenon also observed during the passage of gall-stones 
through the biliary ducts into the duodenum. In other respects, there 
is a close resemblance between the symptoms of stone and those 
sometimes occasioned by inflammation of these parts, when no calcu- 
lous concretion exists. 

Treatment of urinary calculus in the kidney, and during its 
passage from thence into the bladder. — It has already been shown, 
that calculi may exist in the kidney without giving rise to any very 
marked symptoms ; nevertheless, when attending a patient complain- 
ing of dyspeptic symptoms, accompanied by pain in the lumbar re- 
gion, it is our duty to examine the state and appearance of the urine. 
The remarks already made must be kept in recollection, and par- 
ticularly that renal calculi are chiefly composed of lithic acid, the ex- 
cess of which gives to the urine a red colour, and when there is any 
deposition on the sides of the vessel, it will be of a red or pinkish co- 
lour. In such circumstances, the use of alkalies will be found very 
serviceable, and more particularly Henry's calcined magnesia. The 
alkalies in common use are lime-water, the subcarbonates of soda 
and potash; and I frequently exhibit the liquor potassae in milk. 
The warm bath, hot fomentations to the loins and rubefacients may 
be employed, and will frequently relieve the pain. Local bleeding 
by cupping may also be had recourse to when necessary. Opiates 
are serviceable in allaying pain, particularly when it is violent, and 
when suspicion is entertained of a calculus passing through the ure- 
ter; the dose must at that time be proportioned to the severity of the 



STONE IN THE BLADDER. T29 

sufferings ; indeed, general bleeding is then frequently necessary. In 
both conditions, gentle laxatives are indispensable, assisted by large 
tepid injections. 



STONE IN THE BLADDER. 

Symptoms. — A frequent desire to pass urine, an uneasy sensation 
in the glans, and pain in the region of the bladder, are the chief symp- 
toms complained of. The uneasiness in the glans becomes at last 
very acute. The urine varies in appearance, depositing sometimes 
a red, at others a white sediment ; there is often a considerable quan- 
tity of mucus, sometimes tinged with blood, produced no doubt by 
constant irritation and inflammation of the mucous membrane of the 
bladder; the urine sometimes flows only drop by drop, with great 
straining, owing, perhaps, to the enlargement of the prostate gland, 
or to the stone being lodged in the neck of the bladder. Occasion- 
ally the urine flows in a full stream, but suddenly stops with violent 
pain, which is generally attributed to the stone pressing on the orifice. 
This inconvenience is frequently relieved by change of posture. 
Thus I have known several patients who were never Jible to make 
water, unless lying on one side ; and instances are recorded by Sir 
James Earle, of patients who, " in order to evacuate their urine, were 
literally obliged to stand on the head almost in a vertical position." 

The symptoms above enumerated are not always present, but 
come on at times in severe paroxysms, which are known by the 
term " fits of the stone ;" these are occasionally produced and exas- 
perated by exercise of any kind, but particularly by riding on horse- 
back. Instances are recorded in which stones of considerable size 
have been found in the bladder after death without having produced 
much, if any previous suffering; but in these cases they have gene- 
rally been found contained in cysts. 

(in dissection of patients who have died with calculus, the bladder 
:i more or less thickened, diminished in size : and the 
;is membrane is also frequently found extensively diseased, 
book times ulcerated. 

Treatment of atone in il><- bladder, — A stone in the bladder, if 

small, may pass through the urethra, and tins is a frequent occur- 
rence ; but when large, the only prospect of curing the patient is by 
means of a surgical operation, winch tins is not the place to describe,. 
Various chemical agents, some of an arid, others of an alkaline na- 
ture, have been recommended to be thrown into the bladder, for the 
purpose of dissolving calculi; but as it has been already shown that 
the composition of urinary calculi is various, and that each may con- 

if different substances in distinct layers round a common nucleus, 
little benefit can be expected from their employment, Besides tins 
objection, the introduction of such fluids must exasperate the patient's 

ring m all eases by irritating the Madder, if used Sufficiently con- 
centrated to exert any solvent effect 

As palliatives, L"'iit!c laxatives, tepid injections thrown into the 
.,1* 



730 STONE IN THE PROSTATE. 

rectum, opiates, perfect rest, the warm bath, and attention to diet 
will be found beneficial. 

For further particulars respecting the treatment of stone in the 
bladder, and for many ingenious remarks concerning the operations 

Marcet's work. 



STONE IN THE URETHRA. 

Symptoms. — At first this affection may be mistaken for stricture, 
but the impression will generally be removed by the introduction of 
a metallic bougie or a catheter. But even if neither of these be used, 
the nature of the case is soon unequivocally announced by a partial 
or complete retention of urine, by acute pain in the situation of the 
calculus, by the hardness of its feel, and by subsequent inflammation 
and tumefaction of the part. 

This also is a case for the surgeon; but I may mention a plan 
which prevails among quacks, of giving strong diuretics to produce 
a copious secretion of urine, with a view of expelling the stone by 
creating a deluge; but this is to be regarded as a rash and danger- 
ous practice, which no sensible man would venture upon, because it 
might render the operation of puncturing the bladder unavoidable. 



STONES EMBEDDED IN THE PROSTATE. 

Symptoms. — These are very obscure; their detection is difficult, 
and there is no decisive diagnostic. It may be mentioned, however, 
that there is generally a difficulty in making water, with uneasiness 
at the neck of the bladder; when the catheter is introduced, an op- 
portunity may be taken of making an examination per rectum, 
when the prostate gland will be found enlarged. Surgeons, how- 
ever, cannot always expect to be so fortunate as Sir A. Cooper, 
who, on one occasion, felt the stone grate against the catheter; but 
it is necessary, in all gravelish cases, to make a very minute exami- 
nation. 

With respect to the occurrence of calculous disorders, it may be 
mentioned, that males are more liable than females — that they chief- 
ly affect the studious and sedentary — and it is rare to see an instance 
of stone in warm climates. 



CHAPTER III. 



SUPPRESSION OF URINE— RETENTION OF URINE- 
INCONTINENCE OF URINE. 



SUPPRESSION OF URINE. 



A partial and sometimes a total suppression of urine takes place 
in most cases of fever, and for the most part also in severe inflamma- 
tion of various organs; and it has been already shown to be a con- 
sequence of inflammation of the kidneys. But as the term is now- 
used, I mean to express a suppression of urine from failure in the 
secreting powers of the kidneys, sometimes, though not generally, 
accompanied by violent suffering: Suppression of urine, however, 
leads sooner or later to very serious consequences, more particularly 
by producing a cerebral affection, which, for the most part, terminates 
fatally. It also appears to be connected with dropsies, of which 1 
shall speak under the proper head. Suppression of urine generally 
occurs in people who are past the meridian of life, although there 
are many exceptions. All the patients seen by Sir Henry Halford, 
before the publication of his paper in the 6th volume of the Medical 
Transactions, "were fat, corpulent men, between fifty and sixty 
years of age;" nevertheless, we sometimes meet with the disease in 
children. It is, I believe, most frequently observed in gouty habits 
after the long-continued application of cold, or subsequent to the 
suppression of an eruption or some habitual discharge. Dissection 
has proved that it is also the consequence of scirrhus and other dis- 
organizations of the kidneys themselves. 

In the genuine disease, there is no desire to make water; but I 
have seen two cases where almost total suppression had continued, in 
one for months, in the other for some weeks, and in which a pretty 
constant desire to make water existed, it being only once in two or 
three days, however, that a small quantity not exceeding two or 
three tablespoonfuls was evacuated, of such an acrid nature as to 
scald the urethra. There is neither pain nor tumefaction above the 
pubes denoting a full state of the bladder; but to determine tlit 1 . 
point, it is wise to introduce a catheter, which, at all events, has the 
effect of satisfying the patient. Nausea and constipation, and an 
occasional feeling of sinking, generally attend this complaint. The 
pulse and skin continue for some lime natural, hut the former is oc- 
casionally slower than usual, which always denotes danger. 

In some cases, the symptoms are very distressing from the iirst, 



732 SUPPRESSION OF URINE. 

there being frequent and violent vomiting, hiccup, restlessness and 
severe headache, with pain in the back. In the cases produced by 
disorganization of the kidney, it will be found, upon inquiry, that 
pain and a sense of heat in the loins have been much complained of 
previous to the suppression. It appears to me that a number of the 
cases of this disease, published by Dr. Abercrombie, in the 17th vol- 
ume of the Edinburgh Medical and Surgical Journal, entitled " Is- 
churia Renalis," were really not cases of the disease, but of inflam- 
mation of other organs, attended, as is most frequently the case, with 
more or less suppression of urine ; I more particularly allude to 
three out of the five cases which that gentleman has recorded. 

It has been very generally remarked, that there is great sympathy 
between the functions of the skin and the kidneys, for, during warm 
weather, when there is a copious secretion from the skin, little urine 
is discharged; and in cold weather, when the determination to the 
skin is diminished, the urine is observed to be in larger quantity. In 
the disease now under consideration, there is sometimes profuse 
sweating, and in three of Sir Henry Halford's cases, the perspiration 
was observed to have a strong urinous smell. 

For the most part this disease is speedily fatal, and seems to be so 
by producing diseased action in the brain, terminating in coma and 
death. In other cases, a train of symptoms denoting inflammation 
of the brain occurs with paralysis; and the first instance in which I 
ever remarked the combination of rigidity of the flexor muscles and 
paralysis, was in a case of this kind. 

Sir Henry Halford states, in relating the history of one of his cases, 
that " the patient sat up in bed and conversed as usual, complaining 
of some nausea, but of nothing material in his own view ; and I 
remember that his friends expressed their surprise that so much 
importance should be attached to so little apparent illness. The 
patient's pulse was somewhat slower than usual, and sometimes he 
was heavy and oppressed. I ventured to state, that if we should not 
succeed in making the kidneys act, the patient would soon become 
comatose, and would probably die the following night; for this was 
the course of the malady in every other instance which I had seen. 
It happened so; he died in thirty hours after this in a state of stupe- 
faction." It must be observed, however, that the cases do not al- 
ways terminate fatally, and that many run a much longer course. 

Three cases have fallen under my care in men far advanced in 
life, in two of which the suppression was almost complete for two or 
three weeks at a time, without giving rise to any troublesome train 
of symptoms, and for many days it was entirely suppressed ; I believe 
they are both still alive, at least I know for a certainty that one is. 
Dr. Parr, in his Dictionary, under the article " Ischuria," mentions 
a similar case, in which no urine was secreted for six weeks ; and 
Dr. Laing, in 10th vol. Edinburgh Medical and Surgical Journal, has 
described a case in which there was a complete suppression of urine 
for nine days, and yet the patient got well. 

Many years ago I saw a very interesting case, of which the fol- 
owing is a sketch : — A gentleman, aged 72, who had always enjoyed 
good health, with the exception of seven or eight severe attacks of 



SUPPRESSION OF URINE. 733 

gout, under which he had formerly laboured, was seized with a par- 
tial suppression of urine for four mouths, when it became almost 
entirely suppressed. His illness continued for ten months, during 
which he fell off in flesh j his strength diminished; and his temper 
became very irritable. During the last four months of his life, when 
the urine was almost totally suppressed, he complained frequently of 
headache and weakness of one side of his body. His face and head 
were often observed to be flushed, particularly when irritated and 
after meals. He had frequent desire to make water, (probably ow- 
ing to disease of the prostate, which was found after death,) but 
rendered only a tablespoonful or two once in two or three days; 
nevertheless, he used to stand for an hour with the chamber-pot in 
his hand, supposing that he was making water all the time; and he 
had also a notion that he was always perspiring very freely, al- 
though there was never the least moisture upon his skin. During 
this time, and up to within a few days of his death, diuretic medi- 
cines and saline purgatives were assiduously administered, and he 
was encouraged by his medical attendants to take two or three glasses 
of strong gin and water daily, to assist the secreting powers of the 
kidneys. It was at this time that I first saw him, and found that 
he was dying from the effects of inflammation of the brain; besides 
other symptoms, there was paralysis, with rigidity of the arm. On 
dissection, the central parts of the brain were found in a state of 
ramollissement, with effusion into the ventricles, and great vascu- 
larity, not only of the membranes, but of the substance of the brain. 
There was no diseased appearance about the kidneys, but a flabbi- 
ness ; the bladder was much contracted; the prostate gland was 
enlarged, indurated, and contained a white calculus, in its substance, 
about the size of a large garden-pea. It is too evident, from the 
history of the case, that the patient was mismanaged, and that the 
affection of the brain was altogether overlooked. 

Treatment ofwppreuion '[/'urine. — Much mischief is occasioned, 
in many cases of diminished secretion of urine, by the indiscriminate 
employment of diuretics, I believe this class of remedies is chiefly 
serviceable in promoting an increased flow of urine at the decline of 
the disease, after the functions of the kidneys have been considerably 
restored, when a combination of squills, calomel and digitalis, in the 
form of pill, in the proportion of half a gram of the two former sub- 
Mancei and two or three of the latter, may be used and repeated 
three tunes a day. Bui should the mouth become affected, the calo- 
mel is to be omitted. Cream of tartar is also to be given freely, and 
may be occasionally changed for some vegetable infusion of known 
diuretic qualities, such as juniper, broom, &c. Balsam of copaiva, 
oil of turpentine, sweet ipiril ol nitre and tincture of cantharides, in 
small doses, an- often administered, ami sometimes with effect ; but 
ill. y ought to be given With great caution, and under tho restriction 
already ipokeo Of! 

The principal point to be attended to is to excite the skin and 
tin; bowed in a powerful manner alternately, the latter by means of 
neutral salta dissolved in a large quantity of water, Practitioners 
Should anxiously watch cases ol tins nature, in order to discover the 



7S4 RETENTION OF URINE. 

approach of any affection of the brain, which is to be combated upon 
the principles laid down in another part of the work. Should there 
be pain in the region of the kidneys, it may be relieved by local ab- 
stractions of blood — by the application of rubefacients, or even of 
blisters. 

RETENTION OF URINE. 

This term ought to be restricted to an inability to evacuate urine 
from the bladder, which may be more or less distended by the secre- 
tion. Retention of urine is sometimes the consequence of a diseased 
condition of the brain, spinal marrow or the nerves supplying the 
bladder itself; it is occasionally a symptom of stone in the bladder, 
but more particularly of disease of the prostate gland, and stricture 
in the course of the urethra. It is frequently produced by neglecting 
to empty the bladder in due time, when the organ subsequently be- 
comes filled to such a degree as to be either paralyzed, or merely 
unable to act from over-distension. 

The symptoms are, pain in the region of the bladder, with frequent 
and violent desire to make water, and bearing-down efforts, exactly 
as in labour. Occasionally there is tenesmus, and if the patient be 
not soon relieved, the pain extends along the course of the ureters to 
the loins. The distended bladder is to be felt above the symphysis 
of the pubis; sometimes its fundus reaches as high as the umbilicus. 
Generally there are constitutional symptoms, such as fever, thirst, 
oppression at the praecordia, together with an anxious expression of 
countenance, and occasionally severe headache. 

The danger to be apprehended is not that the bladder shall burst, 
but that peritoneal inflammation shall ensue. Instances are stated 
where sixteen pints of urine have been evacuated from the bladder, 
which seems almost incredible, if we did not know how greatly the 
organ is capable of being distended. 1 have myself seen more than 
one instance where eight pints have been drawn off. When de- 
scribing the appearances found on dissection in erysipelas, the case of 
a woman was mentioned, where the urine, during a second attack of 
retention, escaped at the umbilicus, in consequence of the fundus of 
the bladder becoming attached by adhesive inflammation to the peri- 
toneum corresponding to the umbilicus, and ulcerative absorption 
taking place. I have now to mention that, four years previously, 
this woman had had retention of urine for four days before she was 
relieved by the catheter, and I was informed that sixteen pints of 
urine were then evacuated. It appeared, from the strength of the 
adhesion between the fundus of the bladder and the umbilicus, that 
it was at that period the adhesion had taken place. 

We must keep in mind that a distended bladder sometimes takes 
place in women during the early months of pregnancy, in connection 
with a displacement of the uterus, termed "retroversion," in which 
case its cervix will press against the neck of the bladder or the ure- 
thra, and occasion a mechanical obstacle to the flow of urine. Re- 
tention of urine also sometimes follows delivery in consequence of 
the long continuance of the pressure to which the urethra and neck 



INCONTINENCE OF URINE. 735 

of the bladder have been subjected, during the passage of the child's 
head. 

Treatment of retention of urine. — The principal remedy is the 
introduction of the catheter ; but as this is sometimes objected to by- 
men from the apprehension of its being a painful operation and by 
females from natural delicacy, it is often necessary first to try other 
expedients. The chief of these are the use of the hip-bath, or hot 
fomentations to the region of the pubis; large, tepid and nnstimulat- 
ing injections into the rectum; the internal exhibition of camphor 
and opium or hyoscyamus, the tincture of the muriate of iron ; or 
sweet spt. of nitre. When these remedies fail, it has been recom- 
mended to employ injections of the infusion of tobacco. The use of 
the catheter may sometimes be avoided by the simple expedient of 
pouring water in a continued stream from one vessel to another 
within the hearing of the patient ; but this I imagine can be effectual 
only when the retention is produced by a spasmodic affection near 
the neck of the bladder, or by a general paralysis of the fibres of the 
organ. A medical gentleman lately mentioned to me, that he has 
rarely failed in relieving the retention, when there was no permanent 
obstruction, by giving doses of from ten to twenty drops of the vin. 
nicot. tabaci every second or third hour. 

[The free administration of strychnine or of the tincture of mix 
vomica, will sometimes bring on contraction of the bladder, with 
consequent relief of all the symptoms. When, however, it becomes 
necessary to introduce the catheter, the operation is called for three 
or four times every twenty-four hours, as the difficulty recurs with 
every accumulation of urine. To obviate this difficulty, I have ef- 
fected radical cures by allowing the catheter to remain several hours 
in the bladder, by which means the latter is enabled to contract upon 
itself, and gradually to recover its tone. I derived this hint from 
Dr. Hartshorne of this city, with whom I lately attended a gentle- 
man whose bladder continued in a completely torpid state, in defi- 
ance of all our measures for relief, until the above plan was adopted. 
The result was a speedy and perfect cure.] 

When called to a case of this kind, we must take a general view 
of the symptoms, the duration of the distension, the general condi- 
tion ol the abdomen, together with the state of the pulse, the heat 
of the surface, and the expression of countenance, in order to deter- 
mine whether peritoneal inflammation exists. Should this be the 
case, general bleeding or the application of leeches must be had re- 
course to : and it must not be forgotten, that when the complaint 
terminates fatally, the event is, in general, produced by peritonitis. 

In treating tins affection, we must not be deceived and lulled into 
security by the patient's passing a small quantity of urine, as it 
sometimes dribbles away, when the bladder is ready to burst from 

over-distension. 

INCONI 1M:.\i K OK URINE. 

Wsil a person cannot retain urine in the bladder, but constantly 

passes it involuntarily as quickly as secreted, he is said to labour 



736 INCONTINENCE OF URINE. 

under incontinence of urine. It is a frequent attendant on paralytic 
disorders, which produce atony of the sphincter of the bladder; it 
may also be caused by acrid urine, stimulating the bladder to con- 
tract, as soon as it has entered it, and also by irritation about the 
bladder or urethra. 

In the case proceeding from paralysis, the best remedies are the 
application of a blister to the upper part of the sacrum — the internal 
use of the tincture of cantharides, in doses of from ten to twenty 
drops three times a day, in a wineglassful of linseed tea, or a little 
mucilage— and also cold bathing. If it proceed from acrid urine, 
diluents should be employed, particularly linseed tea, together with 
cooling laxatives, and the introduction of the catheter will be found 
serviceable. 

The incontinence of urine which proceeds from irritation or in- 
flammation about the neck of the bladder and urethra, may also be 
produced by acrid urine, or by sand or gravel passing through the 
urethra. If there be a superabundance of lithic acid, alkalies should 
be administered, and in severe cases it is serviceable to throw tepid 
water into the bladder. Anodyne injections are also to be used. In 
all cases where there are pain and irritation in the urinary organs, 
the pills formerly mentioned, composed of equal parts of camphor 
and hyoscyamus, should be administered. 

[I have been often consulted in reference to incontinence of urine 
in children, and have, in nine cases out of ten, been able to trace it 
to a bad habit, brought about by the negligence of nurses or other 
attendants. In some seemingly inveterate cases of this kind, I have 
completely overcome the disorder by having the subject of it waked 
at stated intervals during the night, for the purpose of evacuating 
the bladder. At first, nut more than four hours should elapse be- 
tween the evacuations; but the interval may soon be somewhat 
lengthened. By a persistence in this plan, the neck of the bladder 
becomes susceptible to the stimulus of the urine, the patient wakes 
accordingly for relief, and a filthy and most distressing weakness is 
thus speedily eradicated.] 



SYPHILIS. r4 g 

Various eruptions on the skin also occur, assuming the form of 
papulae, pustulae, squamae; and, iti fact, there is scarcely a form of 
disease noticed in Willan's orders or species, which we do not occa- 
sionally see ranked among the secondary symptoms of syphilis. It 
is said that syphilitic eruptions present a copper-coloured appearance, 
and a diagnosis is too often drawn from this circumstance. 

Inflammation of the periosteum often occurs, particularly on the 
tibia, forming nodes, and the bones themselves sometimes become 
affected, more particularly those of the nose and head, melancholy 
examples of which are to be seen in every museum. 

Inflammation of the iris is alleged to take place during the course 
of syphilitic affections, produced by the specific effects of the virus; 
— the fact is undisputed, but the conclusion as to the cause is more 
than doubtful. 

Secondary symptoms may occur shortly after the healing of a pri- 
mary sore; it is alleged they occasionally do not take place till after 
a considerable lapse of years, although the patient, in the interval, 
may enjoy perfect health. 

Treatment of the primary symptoms of syphilis. — The treat- 
ment of primary sores should be conducted upon the following prin- 
ciples. We should be guided, not by any general theory, but by the 
appearance of the sore itself, and the state of the patient's constitu- 
tion. It should be recollected, however, that the subjects of these 
affections are generally young, thoughtless and dissipated, who have 
contracted the disease after a course of hard living, and were, at the 
time of infection, in a state of high excitement from the use of sti- 
mulants, having also, perhaps, the stomach and bowels in very bad 
condition, contaminating all the secretions of the body. If there be 
much inflammation, pain and swelling, or should the ulceration show 
a tendency either to spread rapidly or to assume a bad character, a 
vein must be opened and a sullicient quantity of blood abstracted; 
and I may state shortly, that I have often been surprised and grati- 
fied at witnessing the immediate benefit of this treatment. I have 
seen large quantities of blood (30 or 40 oz.) taken on such occasions, 
and can safely say, without once observing any bad effects. In the 
circumstances which call for venesection, no external application 
should be made to the part, except warm anodyne fomentations, or* 
perhaps, what will be found still more beneficial, the vapour of hot 
water. 

Antimony is often of considerable service as a contra-stimulant, 
either as an auxiliary to the bleeding, or in cases where the circum- 
stances do not exactly call for the lancet, or when we are afraid to 
use it. 

Laxative medicines are to be occasionally exhibited ; the patient's 
dial should be restricted t<» vegetable substances; and confinement 
to bed lor at least B few days ' s highly necessary, particularly in the 

severe cases now under consideration, 

After the inflammation baa been reduced, and in cases which are 
not attended by any considerable action, but in winch the sores are 

very irritable, the careful application <>i a strong solution of the ni- 
trate of silver (20 grs. to the ounce) is often serviceable. In cases 
63 



750 SYPHILIS. 

which are neither attended by excessive inflammation nor irrita- 
tion, the best application is a small piece of lint, not larger than the 
size of the sore itself; and the part is to be exposed five or six times 
a day to the vapour of hot water, or it may be kept wet with any 
bland liquid. Great cleanliness is necessary in all cases, but as the 
sore is often irritated, and additional inflammation excited by draw- 
ing back the prepuce, the fluid should be thrown up between the 
prepuce and glans by means of a small syringe. On many occasions, 
no further means will be necessary, if we are consulted early ; but 
from various motives, patients are often induced to conceal their 
complaints for a considerable time, and when we see the sores, they 
are found too far advanced for simple remedies. In such circum- 
stances, various washes have been used, as solutions of the acetate 
of lead, sulphates of zinc, copper and alumina and the nitrate of 
silver. The oxymuriate of mercury, as well as the muriate, mixed 
in lime-water, are also frequently used as externa! applications; the 
one is familiarly known by the term "yellow," the other "black 
•wash." The latter is made by throwing a drachm of the submnriate 
into eight ounces of recently prepared lime-water; a precipitation 
takes place of a dark colour. This preparation is more frequently 
used than the yellow wash, and I believe is generally admitted to be 
more efficacious than any other single application. The preparation 
I have used for some years is made in the following manner : an 
ounce of calomel is well and gradually rubbed up with one pound 
of lime-water. After standing for twenty-four hours, the fluid part 
is poured off, leaving the precipitate sufficiently moist to be applied 
■with a hair-pencil to the affected part, without the intervention of 
lint or linen. In making choice of any particular lotion, it is found 
to be a good rule to change from one to another, should the sore 
show no appearance of amendment in the course of three or four 
days. 

Various ointments have been also often used— of these, the com- 
mon mercurial and the red precipitate stand in the highest estima- 
tion ; but it has been generally found that greasy applications do not 
answer well. When astringent or stimulating preparations are re- 
quired, their strength must be regulated by the effects they produce 
on the part ; slight temporary pain should be occasioned when we 
wish to excite a little increased action ; when, however, the sore is 
in a very indolent state, a strong solution of the nitrate of silver will, 
upon the whole, be found to be most effectual; the solid caustic itself 
is often necessary, particularly when a tendency is shown towards 
the formation of warts. 

In treating cases of primary sores, whatever may be their exter- 
nal character, whether they succeed impure connection or not, my 
plan has been to treat them iu the manner above described in the 
first instance ; but should there be no decided appearance of amend- 
ment in the course of ten or twelve days, then I am in the habit of 
prescribing a five-grain mercurial pill, morning and evening, and I 
have rarely had occasion to give above eighteen pills before a per- 
manent cure was effected. It has been ascertained, however, by 
numerous experiments performed within the last fifteen years by 



SYPHILIS. 75l 

different individuals in different countries, that all primary sores can 
be eventually healed by the simple non-mercurial plan of treatment; 
and although this practice cannot be called altogether new, still, 
when we reflect upon the immense destruction of human life and 
domestic happiness, created by the diabolical mercurial plan pre- 
viously pursued, the effects of the exertions of every gentleman who 
has been instrumental in proving the safety of the non-mercurial 
treatment cannot be too highly estimated. Although the services 
of Dr. Thomson are well known and acknowledged by many, yet I 
am grieved to see his name passed over in some of the popular 
works of the day. In the learned work of Dr. Mason Good, the 
merit of introducing this practice is entirely referred to Mr. Rose, 
surgeon to the Coldstream regiment of guards. Dr. Mason Good 
states, (vol. iii. p. 388,) that Mr. Rose " was determined to put the 
question to a test, and upon such a scale as might lead to something 
of a decisive result; he forbore, in consequence, about the year 1815, 
to employ mercury for the cure of any case of syphilitic affection." 

It is well known that Dr. Thomson led the way, both by precept 
and example, long previous to IS 15 ; and, if I recollect right, it was 
in consequence of the views which Dr. Thomson gave in his course 
of lectures on surgery, that I was induced, in the year 1808, to treat 
more than one case of chancre without mercury, which had all the 
appearances of true syphilis. In one instance secondary symptoms 
ensued in the form of sore throat and eruption, which were also suc- 
cessfully and permanently cured upon the same principles; and it so 
happens, that I have still an opportunity, from frequent intercourse 
with the individual, to know that he has never suffered from the 
plan pursued, and that he has a large family of healthy children. I 
also recollect, when I first took charge of the sick in the Ordnance 
Hospital at Leith Fort, in the beginning of the year 1811, having 
been strongly advised by Dr. Thomson not to give mercury. Dr. 
Thomson's opinions were well known both at home and abroad be- 
fore the year 181.5, at which period I believe there was not a mili- 
tary or naval surgeon in the service of Great Britain who was not 
aware of them ; therefore it must be acknowledged that Dr. Thom- 
son has not received that merit which is justly his due, as will be 
seen by the following extract copied from the work abovemen- 
tioned : — "The experimental course laid down by Mr. Rose was 
soon adopted by others, and, on various occasions, carried intoestab- 
Kshmenta which afforded ample space for a satisfactory examination. 
It was tried in other battalions of the guards, as well in France as 
at home; was introduced into the York Hospital at Chelsea, and 
various other establishments, as at Dover, Chatham and Edinburgh." 
(P. 888.) 

These observations are not dictated by feelings of personal friend- 
ship, but arc made from a strict sense of justice towards Dr. Thom- 
son. 

It cannot now be denied, thai all syphilitic sores may heal with- 
out having recourse to mercury; and, on the other hand, it is known 

that by a judicious DM Of various preparations Of that mineral, the 
same event may take place. Hut an interesting question innniili- 



752 SYPHILIS. 

ately suggests itself. — By which plan will a cure be most speedily 
and effectually obtained? I have found that, according to either 
plan, permanent and effectual cures are produced, but more speedily 
under the judicious use of mercury, along with blood-letting and the 
other means, local and constitutional, which have been already no- 
ticed. But there are constitutions that cannot bear the action of 
mercury, and upon which it produces poisonous effects. 

Although I should be entitled to insist on the force of these ob- 
servations, drawn from my own practice, yet they are rendered still 
more worthy of confidence by the united testimony of a number of 
gentlemen who have directed their attention to the settling of this 
important question. Dr. Hill, who has written an excellent paper 
on the simple treatment of syphilis, in the ISth vol. of the Edinburgh 
Medical and Surgical Journal, candidly states, at p. 590, that second- 
ary symptoms occurred in a greater proportion under his treatment, 
than after that by mercury; yet he assures us that these affections 
are of a milder and more tractable nature. In the practice of Staff- 
Surgeon Murray, Mr. Evans, of the 57th regiment, and Mr. Brown, 
of the staff-corps of cavalry, the proportion of secondary symptoms to 
the whole number of cases has been about a tenth. Mr. Guthrie, 
deputy inspector of military hospitals, now a surgeon in extensive 
practice in London, in a paper published in the 8th vol. of the Me- 
dico-Chirurgical Transactions of London, makes the following ob- 
servations, at page 508: "The fact I have stated as to the non- 
occurrence of secondary symptoms in regimental hospitals, where all 
doubtful cases were treated by mercury, is so positive, that 1 am 
certain no regimental surgeon of ability will be found to contradict 
it. - That they did sometimes occur is true, but it was only when 
the troops were moving, and under irregular management that they 
were numerous, and then only in the general hospitals, where all the 
stragglers and all the bad and protracted cases are collected. In 
the half year ending the 24th June, nearly 1400 cases of primary 
symptoms were treated in the army in France by mercury, and in 
this period only 14 cases of secondary symptoms occurred." And 
in another place he states, " In six regiments in one district in Eng- 
land, 521 cases were treated in fifteen months by mercury, and ten 
cases of secondary symptoms appeared ; so that the true average 
proportion is 1 in 75." 

Notwithstanding these statements, it is evident there are no data 
on which any calculation can safely be made respecting the propor- 
tion of secondary symptoms succeeding to either plan of treatment. 
Some practitioners call every eruption on the skin and slight relaxa- 
tion of the throat and rheumatic pains secondary symptoms. Others 
place only the worst description of such cases under that denomina- 
tion ; which circumstances I have often witnessed, both on the part of 
mercurialists and anti-mercurialists. A great majority of the cases 
of eruptions and sore throats, occurring under both symptoms of 
treatment, are generally to be attributed to affections of the stomach 
and bowels, produced by the remedies employed in peculiar constitu- 
tions ; and that they should more frequently occur under the usual 
plan adopted by the anti-mercurialists is not surprising. No means 



SYPHILIS. 753 

are more likely to weaken the functions of the stomach and bowels, 
and, indeed, the actions of the whole system, than long-continued con- 
finement to bed, the use of slops, and drenching patients with two or 
three pounds of the decoction of sarsaparilla daily. Such treatment 
will enable us to account very well for the longer period required to 
heal sores upon the anti-mercurial plan than the other. On many 
occasions, chancres of long standing have healed immediately, after 
patients have been allowed solid food, and a little wine or porter, 
sometimes with, sometimes without, a few blue pills. 

In former days, when large quantities of mercury were given, and 
persisted in for a long period of time, secondary symptoms were far 
more frequent than at present; and in calculating the benefit derived 
from the labours of the non-mercurialists, they are fairly entitled to 
the credit of the remarkable change which has taken place, as well 
as of showing that secondary symptoms do not occur nearly so often 
as was imagined ; that they are rarely dangerous, and may in many 
instances, be cured, perhaps not so speedily, but quite as effectually 
without as with mercury. 

A curious fact may be mentioned respecting the black wash, which 
applies equally to all other mercurial applications. Some years ago, 
when I was carrying on investigations respecting the comparative 
advantages of the different modes of treating syphilis, I was sur- 
prised to find, on visiting the hospital in the Castle of Edinburgh, 
that the primary sores were healed in a much shorter space of time 
than in the Royal Ordnance Hospital at Leith Fort, although 1 had 
two advantages which they did not enjoy, viz.: a better and a less 
crowded hospital, and men, generally speaking, of stronger consti- 
tution. Upon expressing my surprise at this circumstance, I was 
asked by one of the medical officers if I used the black wash, for 
that they had found it the most effectual application. My reply was, 
that I had not considered it fair to use any mercurial preparation 
whatever, when endeavouring to ascertain the effects of the non- 
mercurial plan of treatment; but I resolved after that to try it. Ac- 
cordingly, the black wash was prepared, and the first subjects to 
whom it was applied were two men who had been upwards of 
thirty days in t lie hospital without any amendment of the sores. 
On the seventh day, the healing process was observed in the sores in 
both cases; but one of the men asked me to allow him porridge in- 
stead of bis bread, which he could "not eat on account of the state 
of his teeth." Next day he made the same request, and begged me to 
look at his mouth : the state of the gums and the fetor of the breath 
announced the effects of mercury upon the system, which attracted 
my attention and induced me to examine the mouth of the other 
man who was in another ward ; he was found to be in a similar 
state, but slighter in degree. On the next public day, I returned to 
the castle, and announced the circumstance before Dr. Thomson and 
a considerable number of other gentlemen, who said it must have 
been accidental, and that it had never been observed in their hos- 
pital. It was readily granted on my part that it might be accidental, 
but that it certainly deserved attention, having occurred in two con- 
secutive cases. Salivation never having been observed in the castlo 

63* 



754 SYPHILIS. 

was no argument, because I had no doubt the event had never been 
looked for, and, perhaps, would never have been observed by me 
had not one of the patients asked for a change of diet. We soon 
went up stairs into the wards; the gums of some patients were ex- 
amined, who were using the black wash, and two or three of them 
were observed to be under the influence of mercury. It was then 
calculated, that the hundred-thousandth part of a grain of mercury 
could not have been received into the system by means of the appli- 
cation of the black wash to such a small extent of surface. My an- 
swer to which was, that the calculation was merely a guess, and that 
it was immaterial to the point at issue how small or how large a 
quantity would affect the system. 

At that time I was attending a young lady who had a small sore, 
of the nature of lupus, upon the nose, to which the black wash was 
applied, out of the same bottle from which the two men had been 
supplied. On the ninth day, she complained of her mouth being 
very sore, and of having a copperish taste ; upon examination, the 
gums were found to be swollen, spongy and inflamed, the breath 
having the mercurial odour. Since that period I have applied the 
black wash to many cases of all descriptions of ulcers, and in two- 
thirds of these some degree of soreness in the mouth has been pro- 
duced, with considerable mercurial fetor, in the space of from the 
fifth to the tenth day. In all these cases, the sores healed more 
rapidly than in the remaining third; and a circumstance worthy of 
being mentioned has been observed — that from the moment the 
sores began to cicatrize, the effects of the mercury upon the mouth 
declined, although the application of the black wash was continued; 
and in some, for the sake of experiment, it was persevered in for 
fourteen days, notwithstanding which the mercurial effects disap- 
peared. 

Treatment of buboes. — When inflammation of the glands in the 
groin is first observed, the patient should be advised to use no exer- 
cise, and, if possible, confine himself to bed, more particularly if he 
show any of the appearances of a bad constitution, or even tempo- 
rary bad habit of body. If there be much redness and pain, leeches 
should be applied, succeeded by a poultice or warm fomentations; 
and sure am I, that should suppuration eventually follow, it will be 
much less extensive than if leeches had not been used. The matter, 
in the event of suppuration, should be let out as soon as possible, 
by means of a moderately sized puncture with a lancet, as the best 
means of diminishing the suffering of the patient, preventing bad 
ulcers and the formation of extensive sinuses. A plan has been 
proposed of opening buboes by means of caustic ; but experience 
obliges me to condemn such roundabout surgical practice. Should 
the parts not show a disposition to heal, much benefit is often de- 
rived from pressure, and also from the application of the solution of 
the sulphate of zinc or nitrate of silver ; indeed, the edges of the inci- 
sion sometimes require to be touched with the latter in substance. 
A generous diet is sometimes necessary, and the occasional use of 
wine is frequently found advantageous. 



SECONDARY SYPHILIS. 755 



Treatment of Secondary Symptoms of Syphilis. 

1. Sore throat.— This form of secondary symptoms is to be treated 
upon general principles. From the eifects produced in a great num- 
ber of cases, I cannot speak too highly of the external application 
of leeches and blisters, when the inflammation and swelling in the 
throat are considerable, and when the ulcers are active and irritable; 
but in other circumstances, a solution of the nitrate of silver, in the 
proportion of twenty or thirty grains to the ounce of distilled water, 
is to be applied by means of a hair pencil to each ulcer. In this 
case the functions of the stomach should be carefully attended to by 
regulation of diet, and the use of gentle laxatives, combined either 
with the sulphate of iron or sulphate of quinine. I have hitherto 
seen no case which has not speedily yielded under this treatment, 
when the sore was within reach. 

2. Eruptions. — It lias already been mentioned, that almost every 
form of known eruptions has been classed among the secondary 
symptoms of syphilis. They are to be treated upon general princi- 
ples, so fully detailed in a former part of this volume : but in intrac- 
table cases, marked benefit will be found to follow the use of the 
alcoholic solution of corrosive sublimate. 

3. Nodes. — In incipient cases, in which the pain is severe, the 
frequent application of leeches to the part affected will be of great 
service, followed by that of blisters; and here again I have to ob- 
serve, that decided advantages will result, in a majority of cases, from 
the use of the corrosive sublimate, aided by the vapour-bath, opiates 
and perfect rest. When the bones come to be extensively diseased 
or carious, surgical treatment must be had recourse to. 

The following deductions have been forced upon my mind, not 
only from my own personal observations, but also from a careful 
consideration of all the facts laid before the profession respecting the 
treatment of syphilis. 

1. That mercury is as certain a poison as arsenic, only it is not so 
quick in its operations upon the system. 

2. That, like many other poisons, it is found useful in the cure and 
alleviation of many diseased states of the constitution, when employed 
with caution, and within certain limits, which can never be defined 
to suit all constitutions. 

3. That it will cure syphilitic diseases, when used judiciously, not 
by any specific effects which it has been long erroneously supposed 
to possess in these diseases, but from its having the power of altering 
or modifying diseased actions, both local and general, improving the 
state of the secretions, and thereby disposing sores to heal; but when 
carried beyond B certain point, which can never be defined, mercury 
produces b disease of its own, always more difficult to cure than the 
primary one for which it was employed. 

4. That all kinds of syphilitic ulcers on the parts of generation, 
including the true Eiunteriao chancre, may be cured without the 
intervention of mercurial preparations, upon the simple plan of treat- 
ment above described. 



756 SECONDARY SYPHILIS. 

5. That secondary symptoms do not succeed the non-mercurial plan 
of treatment in nearly such a great proportion as was apprehended, 
and as is still asserted by some of the mercurialists ; and that when 
they do occur, they are generally mild, unattended by danger, (which 
cannot be said of those produced by over-doses of mercury,) and can 
be cured in a great number of cases without the use of mercury. 

6. It- would appear to be established by all the medical evidence 
which I have had an opportunity of examining, that all the primary 
forms of syphilis are more speedily cured by a judicious use of mer- 
cury than by the non-mercurial plan of treatment. 

It is with much pleasure that I can refer my readers, for most valu- 
able information, to an able work on Syphilis, by J. M. Titley, M.D., 
of London. 



CHAPTER VII. 



DISEASES OF THE LABIA, AND EXTERNAL PARTS, 
IN THE FEMALE. 



PHLEGMON. 



The labia are liable to inflammation and its consequences, not 
only from their situation, bat likewise from acrid discharges, &c. 
Ulceration and phlegmon are two of these effects, but the remarks 
already made when treating of syphilis, are equally applicable to all 
ulcers on the labia, and render it unnecessary to say more upon the 
subject; I shall therefore proceed to treat of phlegmon, which may 
occur at any period of life ; sometimes as the consequence of exter- 
nal injury; at others, it occurs spontaneously as phlegmon does in 
other parts of the body. 

Symptoms of phlegmon. — The disease is known by the existence 
of heat, pain, swelling and throbbing, and more or less general fe- 
ver. From the looseness of texture of the part, the progress of the 
disease to suppuration is generally rapid, in which case the pain is 
more severe ; but, in other instances, the disease comes on more 
gradually, the part continues long hard, and the pain is subacute. 
terminations are the same as in phlegmonous inflammation in 
other parts of the body, suppuration being, however, the most tie- 
queot; owing, DO doilbt, t<> a natural feeling of delicacy, which pre- 
vents females from making such complaints known till the disease 
is for advanced. 

Treatment of phlegmon. — There can be no doubt respecting the 
advantages to he derived from the application of leeches early in the 
disease. I ohjcct to cold lotions, because I doubt much if they ever 
prevent suppuration, although they may certainly retard the disease; 
warm fomentations and poultices will be found far more efficacious. 
From the depending position of the parts, and the increase of pain 
produced by motion, the patient should be confined to bed. The 
bowels are to be sept open, and the pain moderated by large opiates. 
Suppuration sometimes takes place in the course of the second day, 

and as BOOH as matter is discovered, it should be evacuated by punc- 
ture; hut there is do necessity for making s large incision, provided 
the al opened in a depending part Prom observing that, 

when Nit to itself, the abscess opens on she inner surface of the labia, 

I generally make the puncture m that situation. It is not good prac- 



758 DISEASES OF THE LABIA, 

tice to introduce a tent, but pressure should be applied by means of 
sufficient compresses, and a T bandage. 

Mortification ought to be a very rare termination; but I have seen 
two cases where sloughing took place, with great loss of substance, 
in consequence of neglect and bad management. 



PECULIAR AFFECTION OF THE PUDENDUM, OCCURRING IN YOUNG 
SUBJECTS. 

In the year 1815, the attention of the profession was directed to 
the history of a very fatal affection of the pudendum of children, by 
Mr. Kinder Wood, surgeon in Oldham, now in Manchester. Of this 
affection he had seen twelve cases before he wrote his paper in the 
7th vol. of the Medico-Chirurgical Transactions, London. The pa- 
tients were from one to six years of age. Two only recovered. 
The complaint commences, according to Mr. Wood, " with chilli- 
ness, succeeded by heat; slight pain in the head; dnlness, nausea; 
loss of appetite and thirst; the tongue has a clay-coloured deposit ; 
the bowels are torpid; and the patient is languid, inert and listless. 
These symptoms precede the affection of the pudendum about three 
days. When the genital organs are examined, one or both labia are 
found inflamed and enlarged ; the inflammation is of a dark tint, and 
soon extends internally over the clitoris, nymphae and hymen, and 
a thin secretion, which, at this period, may be observed coming from 
these parts, renders it not improbable that the lower part of the va- 
gina may be affected." In a dissection, at which I was present with 
Mr. Cheyne and Dr. Combe of Leith, and which was also attended 
by Professor Bene and his son from Hungary, when on a tour in 
this country, the inflammation, which terminated in mortification, 
had extended high up in the vagina. 

Ulcerations soon take place, generally of a bad character, having a 
dirty yellow appearance. In Mr. Wood's cases the discharge was 
peculiarly offensive, copious, irritating the adjacent parts, and con- 
tributing to extend the disease along the peritoneum to the anus and 
to the inner part of the top of the thigh, contiguous to the labia. He 
has also seen the inflammation spread over the mons veneris, and, 
succeeded by deep ulcerations, progressively extending as long as 
life continued. "The pulse, (says Mr. Wood,) is quick and irritable 
after the inflammation commences, and, as the ulceration extends, 
the face becomes of a peculiar pallid hue, the skin having a very 
singular whiteness, which I have never seen absent after the ulcer- 
ations had formed. The stools are slimy and offensive; and, in two 
or three cases, I have seen aphthae spread extensively around the 
anus and over the peritoneum. The ulcerations in this affection are 
not of an equal depth or appearance, but various in this respect, as 
well as in the state of the bottom, which, in some places, is foul as 
well as deep, in others, superficial and sprinkled with small red gra- 
nulations." Mr. Wood further states that, in his cases, the pain on 
motion was excessive, and that retention of urine, with its usual 
concomitants, formed an important train of symptoms. The course 



AND EXTERNAL PARTS, IN THE FEMALE. 759 

of the disease does not appear to occupy any regular period, but, 
"from the time that the ulcerative action is completely established, 
the enlarged labia diminish and the redness disappears, the ulcer 
successively extending over parts which had been inflamed. The 
character of the disease, at this time, is that of a deep, foul and 
spreading ulcer, upon parts weakened by a peculiar inflammation 
and a constitution injured and weakened by previous febrile symp- 
toms. The external organs of generation are now progressively' 
destroyed; the peculiar pallor of the countenance increases; the 
pulse becomes quick and weak ; the appetite fails; the bowels become 
loose ; the skin of the thighs hangs loose and flabby, as in marasmus; 
the discharge from the parts increases and becomes more and more 
offensive, till the patient is worn out and expires." But, in all the 
cases but one which I have seen, the progress was different ; the 
ulcerations were not extensive, and the external swelling and dark- 
red colour continued to the last, and, in two cases, even after death. 

The duration of this curious affection is various: — "In one case, 
the patient got better in twenty-three days, in another, in seventeen 
days; but it is not possible to say what may be the duration of a 
fatal disease, this depending on many circumstances of violence, con- 
stitution, &c. When the ulceration is deep and extensive, I have 
never seen the patient recover." Mr. Wood presumes that this 
affection bears a much stronger similarity to infantile erysipelas than 
to any other disease. 

The first case of this affection that fell under my observation 
occurred several years ago, in my dispensary practice. The patient, 
a girl of six years of age, when recovering from measles, during the 
progress of which there had been great gastro-intestinal irritation 
and diarrhoea, was seized with the disease of the pudendum, and 
died in the course of eight days. Every effort was made to obtain 
permission to examine the body, without success, but I saw sufficient 
to convince me that the child died, not so much from the effects of 
the external disease as from inflammation, and perhaps ulceration 
of the mucous membrane of the bowels. Some time afterwards I 
was asked by Dr. Moffit, of the 7th Hussars, to see a child labouring 
under the disease at Pienhill Barracks; she was also attacked with 
it immediately after the recession of the eruption in measles, which 
had been mild, but attended with diarrhoea. The external inflam- 
mation, pain and swelling of the pudendum were fully as great as 
in the former case, and bore such a strong resemblance, in its external 
characters, that any one would have readily recognized the alfection 
from a drawing in my portfolio. This child recovered under the use 
of poultices and fomentations, and the exhibition of gentle laxatives. 
Since then, several fatal cases have occurred in Edinburgh, and the 
appearances on dissection were Mich as to confirm tin' opinion I 
hid pre rionsly entertained— the mucotu membrane of the bowels 
displaying extensive vascularity and ulceration, particularly in the 
ileum. In "in: of the Cases tin: ulcerations were numerous and ex- 
tensive; ami in th<; oilier, the mUCOUl membrane was found thickened 
and spongy in many places, and in the usual progress towards ulcer- 



760 DISEASES OF THE LABIA, &c , IN THE FEMALE. 

ation, which would certainly have taken place had the child lived a 
few days longer. 

It would appear that Dr. Ferriar, of Manchester, was familiar 
with this affection, for he states, in his excellent work, entitled 
"Medical Histories and Reflections," that he had "met with several 
instances of putrid fevers in young girls, accompanied with broad 
maculae on the body and limbs, and a gangrenous state of the labia 
pudendi. The parts were greatly tumefied and extremely painful. 
It was a very fatal complaint." (P. 169.) 

Treatment. — Mr. Wood remarks that the first part of the treat- 
ment is to move the sluggish bowels with calomel and rhubarb ; the 
affected part should be frequently washed with the liquor plumbi 
acetatis dilutus slightly warmed, and poultices, made of the same 
liquor, applied. As soon as the ulcerative action is commenced, he 
considers it necessary to have recourse to bark in decoction, to which 
he commonly added confect. aromat. with tinct. calumb. and small 
doses of tincturi opii, together with a moderate allowance of red 
wine. When the tumefaction and redness were diminished, and the 
ulceration stationary, he applied the ungt. oxyd. plumb, alb., and 
found it very useful. When the bowels became loose, he found the 
elect, mimos. catechu of excellent service, and he gave the bark in 
substance when it could be borne. 

According to the views which I have been led to form, besides the 
local treatment recommended above, such means ought to be taken 
as will cure inflammation and ulceration of the mucous membrane 
of the bowels, which have been so fully described in the first volume. 



CHAPTER VIII. 
INFLAMMATION OF THE TESTES. 



Inflammation of these organs is sometimes produced by external 
injury, or it occurs spontaneously in the course of gonorrhoea, parti- 
cularly the virulent form,, and also during the cure of stricture in the 
urethra by the bougie. It was formerly called hernia humoralis, 
from mistaken notions, by the humoural pathologists. The inflam- 
mation may either attack the part called epididymis, and spread from 
thence to the body of the testicle, or the latter may be originally and 
solely affected. When the body of the testicle is inflamed, the pain 
is very severe, extending along the cord, which, in some cases, is also 
involved in the disease; and occasionally great uneasiness is felt in 
the lumbar region. The pain is increased by pressure, motion, and 
also when the body is in the erect position ; the swelling is sometimes 
very great, and the scrotum frequently reddened and tender. I have 
seen both organs affected simultaneously; but this is rare, the inflam- 
mation generally attacking one only at a time. When the epididy- 
mis is alone affected, the pain is seldom much complained of, and the 
constitutional symptoms are slight; whereas in the other, there are 
sometimes high febrile symptoms, and very frequently nausea, with 
a disposition to faint. 

Treatment qf inflammation of the testes. — The horizontal pos- 
ture in bed must be insisted on, and the part is to be properly sup- 
ported; if the disease be produced by external injury, and be not 
severe, these precautions, together with the employment of laxatives, 
a strictly antiphlogistic regimen and the application of warm foment- 
ations, will sudice. In more severe cases, the internal exhibition of 
antimony as a contra-siiniulant is necessary, with perhaps local bleed- 
ing, which is much better effected by opening one of the superficial 
veins, on the surface of the scrotum, with a lancet, than by the appli- 
cation of leeches, which are tedious, often troublesome, and, on some 
occasions, exceedingly inconvenient, particularly when secrecy is re- 
qoired. When a vein in the scrotum is opened, the patient should 
OS Standing, as die hlood will not flow in the recumbent posture; so 
that when we wish to stop tin- discharge, we have nothing to do hut 
to make him lie down. In very severe cases, however, where the 
swelling is great, the pain severe ami the febrile symptoms high, one 
general bleeding will he ne cessa ry. This proves beneficial by un- 
loading 'he system, and particularly tin: part, of hlood, and by giving 
an effectual, perhaps a permanent check to the diseased action. I 
(.1 



762 INFLAMMATION OF THE TESTES. 

find it very serviceable in the decline of the acute stage of the dis- 
ease, and particularly should there be pain in the course of the sper- 
matic cord, to apply a small blister on the lower part of the abdomen 
in the course of the vessels. After the inflammation has subsided, 
and if any hardness remain, the use of frictions with mercurial oint- 
ment, containing a portion of camphor, will be serviceable, and a 
suspensory bandage must be worn for some time. 

When the inflammation of the testes depends upon inflammation 
or irritation in the urethra, the same plan of treatment is to be had 
recourse to, in addition to such means as may be necessary for the 
removal of the latter affection. Should it seem to be produced by 
the use of the bougie, it must be abandoned for some time, and 
"when recourse is again had to it, a small-sized instrument may be 
used, with additional gentleness and caution. In the treatment of 
this disease, we should feel anxious, not only to mitigate the patient's 
present sufferings, but to employ such means as will prevent any 
subsequent induration. I scarcely ever met with an instance of scir- 
rhus of the testicle, which has not been attributed by the patient to 
some previous injury. 



CHAPTER IX. 

DISEASES OF THE UTERUS CONNECTED WITH 
INFLAMMATORY ACTION. 






In this chapter I shall treat of the following diseases : — 1. Inflam- 
mation of the Uterus after delivery. — 2. Inflammation of the Os and 
Cervix Uteri in the ordinary state of the system. — 3. Vascular Sar- 
coma, Scirrhns, and Cancer of the Uterus. 



INFLAMMATION OF THE UTERUS AFTER DELIVERY. 

This disease has been termed metritis, which implies the existence 
of inflammation of the substance of the uterus. Comparatively 
speaking, it is rare, and we meet, perhaps, with more than fifty cases 
of inflammation of the peritoneal covering of the uterus and its ap- 
pendages, for one of this disease. I have met with it only in two 
instances within the last twenty years— one of which was owing, as 
far as could be ascertained, to long-continued injurious pressure 
which the uterus sustained in a case of difficult labour, occasioned 
by the diminished capacity of the pelvis, and the large size of the 
head of the child; — the other was a very complicated case, occa- 
sioned by rough treatment during labour, and in the extraction of 
the placenta; the bladder in this case was allowed to remain dis- 
tended from Sunday till the following Friday. Several relapses took 
place, attended with pain in the region of the uterus, enlargement of 
that organ, ascertained by internal as well as external examination. 
After many months of Buffering and hectic fever, it was suspected 
that (he uterus contained a fluid, and the channel through the os 
uteri was obliterated. Upon the probability of this opinion, a small 
steel bougie was cautiously introduced through the os uteri, when a 
discharge of about two ounces of fetid pus took place, with a large 
quantity of air. From this time the bad symptoms disappeared, the 
recovery was rapid, and menstruation took place in a few weeks 
subsequent to the operation. 

In a vi'i y severe puerperal epidemic, winch prevailed ftl Vienna in 
the months of July and August, 1819, it is staled that the substance 
of then'' in was always affected ; but upon examining the dissec- 
tion reports, I can find only two Buch instances out of fifty-six. In 
the epidemic which occurred in the Materniti of Paris in the year 
18~9, the uterus is represented SJ having been diseased in one hun- 



764 DISEASES OF THE UTERUS. 

dred and sixty-five cases, and in twenty-nine instances was alone 
affected. 

Not being familiar with the disease myself, I must take the liberty 
of drawing a description from the work of Mr. Burns, of Glasgow, 
who describes it as appearing under two forms. The first takes 
place within the ninth day after delivery, with all the symptoms of 
ephemera, with a dull, heavy pain in the lower part of the belly, 
which is neither constant nor much felt, unless when the patient sits 
up, or when considerable pressure is made with the hand ; but oc- 
casionally a darting pain takes place through the uterine region. 
The state of the lochia, of the milk, the pulse and bowels, are said to 
be various. A discharge of blood like the menstrual is said to be 
critical, as well as the occurrence of free perspiration and diarrhoea. 
The treatment consists in exciting early and free perspiration, foment- 
ing the belly, and opening the bowels. Few cases are said to require 
the use of the lancet or of blisters. 

The second form is said to be more serious from the intensity of 
the inflammation: it commences between the second and the fifth 
day after delivery, but may take place at a later period. The pain 
in the lower part of the belly is severe, increased upon pressure, and 
the uterus is distinctly felt harder and larger than usual ; there is, 
however, no general swelling of the abdomen or tension, unless the 
peritoneum be affected; sometimes nausea and vomiting take place. 
The pulse very soon becomes frequent and somewhat hard, the 
tongue white and dry, and the urine scanty and high-coloured. The 
lochial discharge is early suppressed, and the secretion of milk is 
diminished or destroyed. 

Like the other form, this may terminate favourably by some criti- 
cal discharge, but in many cases, the result is represented to be less 
fortunate: — the febrile symptoms and the pain continue, the pulse 
becomes more frequent, rigors take place, a throbbing of the part is 
felt, symptoms of hectic ensue, the patient spends sleepless nights, 
and is drenched in perspiration. 

"After some time (says Mr. Burns), matter is discharged from the 
vagina, or by the bladder or rectum." " Pus is contained often in 
the ovaria and tubes and sinuses of the uterus. Mortification is an 
extremely rare termination. This is a fact of which my dissections 
convince me, and it is farther confirmed by the opinion of Dr. Clarke. 
Little or no serous effusion takes place into the abdomen." (Page 
426.) 

I strongly suspect that Mr. Burns has confounded this complaint 
with four others — viz., suppression of the lochia, peritonitis, disease of 
the mucous membrane of the bladder, and an affection of the colon 
and rectum. The symptoms occasioned by suppression of the lochia, 
peritonitis and metritis bear such a strong resemblance to each other 
as occasionally to defy all diagnostic distinctions. The pain in peri- 
tonitis is sometimes as dull as that represented in metritis. The 
general description which Mr. Burns has given of the appearance 
found on dissection is very vague; but in detailing the symptoms of 
metritis, he states, that "matter is discharged from the vagina, or 
bladder, or rectum, but oftenest from the rectum." I would here 



DISEASES OF THE UTERUS. ^65 

take the liberty to observe, that although matter is discharged from 
the vagina, it may have proceeded from the uterus; but if discharged 
from the bladder or rectum, these, it appears to me, would be rather 
roundabout ways for the matter to take from the uterus, unless false 
passages have been made by instruments rashly used, or by ulcera- 
tion. Mortification, instead of being a rare occurrence, as stated by 
Mr. Burns, would be a very frequent termination, if the inflamma- 
tion affected the muscular structure of the uterus. The existence of 
pus in the ovaria and tubes is very usually found in puerperal peri- 
tonitis. The assertion of the existence of pus in the sinuses of the 
uterus is vague, as it may be coagulable lymph, which is often dis- 
covered in veins. 

The remedies which Mr. Burns recommends in the second form, 
are the early and free use of the lancet, mild laxatives, fomentations, 
embrocations and sinapisms. The best internal remedy we can em- 
ploy, he says, is saline julep, with antimonial wine and laudanum. 
Emollient and anodyne enemata afford relief. After suppuration 
has taken place, he recommends open bowels, light nourishment, 
fomentations and anodynes. After the matter is discharged, removal 
to the country and tonic medicines are useful. 



INFLAMMATION OF THE OS AND CERVIX UTERI IN THE ORDINARY 
STATE OF THE SYSTEM. 

Experience has convinced me that inflammation of the os and 
cervix uteri occurs more frequently than is generally imagined; that 
it is the cause of much distress to females, by producing diseased 
states of the menstrual discharge and other complaints, more par- 
ticularly ulceration, as well as scirrhous and cancerous affections. 
As the disease falls to be so often mentioned in the following pages, 
I shall now give a description of its symptoms, appearances and 
terminations. 

Tins disease may take place after exposure to cold, fatigue or 
fright, and it is sometimes ushered in with chilliness followed by 
some degree of fever, witli a sense of fulness, weight, heat and pain 
in the proper region, and also in the back and loins— the severity of 
these symptoms depending upon the intensity and extent of the 
inflammation \ in general, however, the inflammation is subacute, 
with corresponding mild symptoms. In the acute cases, the rectum 
appears to suffer, at least tenesmus takes place, the patient experi- 
ences increased suffering when at stool, and occasionally there is 
also micturition. The worst instances that have fallen under my 
notice were connected with diseased states of menstruation, both as 
cause and effect. In most cases there is an increased discharge from 

the vagina, resembling the lencorrhosal ; frequently it is of a sanguine- 
ous nature, and when examined, ifl found partly fluid and partly 

coagulated When the discbarge is copious, the pain in the back is 
generally severe. 

In all serious diseases of the uterus, it is necessary to make a care- 
ful examination of the state of parts, not only by the vagina, hut also 



766 DISEASES OF THE UTERUS. 

by the rectum. On reaching the os uteri, in acute cases, a considera- 
ble increase of pain will be produced by the touch, and will be very 
much complained of every time the finger is made to press upon the 
organ, which feels hot, swollen and doughy ; and I have often been 
aware, during such examinations, of the pulsation of minute arteries. 
Sometimes I have discovered one or more large vesicles which feel 
like minute tubercles; and also ulcerations, particularly on the pos- 
terior lip. In subacute cases, the patient complains of slight increase 
of pain ; upon making an examination, the uterus feels heavy, and 
the lips of the os uteri swollen, irregular and even rough. 

Treatment of inflammation of the os and cervix uteri. — Vene- 
section is occasionally necessary in stout, plethoric women. On the 
continent, the application of leeches to the immediate seat of the dis- 
ease is recommended, and is particularly insisted upon by French 
writers. Formerly I entertained strong prejudices against this prac- 
tice, which a trial, urged by the recommendation of my friend Dr. 
Farquharson, who resided for many years at Lisbon, completely 
removed. The leeches are put into an ivory tube, furnished with a 
piston, and introduced so that the extremity reaches the top of the 
vagina. The piston is then pushed forward. The leeches, in general, 
fasten immediately, and become filled in the course of a few minutes, 
when they make their escape, or are removed with the finger. The 
patient is to sit upon a vessel containing boiling water, to encourage 
the bleeding, which is readily suppressed upon lying in the horizon- 
tal posture. The bowels are to be acted upon by the mildest laxa- 
tives, assisted by injections of tepid water, care being taken that the 
nozzle of the pipe be not pushed against the diseased part. As soon 
as the bowels are in a proper state, anodynes may be used, and are 
found most efficacious when introduced into the rectum. The diet 
should be more or less antiphlogistic, according to circumstances. 
Rest in the horizontal posture is to be enjoined until considerable 
amendment has taken place: and the warm hip-bath seems to be 
serviceable in all cases where there is no considerable haemorrhage. 
I have seen contra-irritation, produced either by tartar-emetic oint- 
ment rubbed upon the lower part of the belly, or by means of a blis- 
ter to the sacrum, beneficial. 

Individuals who have had an attack of this disease are ever after- 
wards liable to a return ; therefore great attention should be paid to 
the bowels, and to preserve the feet sufficiently warm : they should 
wear drawers, and never be without a napkin, or a T bandage made 
of flannel. 

When an ulcer is discovered, it should make little difference in the 
treatment further than to induce us to be, perhaps, a little more active, 
and more peremptory in insisting upon the necessity of keeping the 
horizontal posture. In such cases injections, at first of warm milk 
and water and afterwards of any of the usual astringents, repeated 
several times a day, are necessary. In one case, in which I was 
successful in arresting the progress of, and subsequently healing, a 
large ulceration on the lip of the os uteri, I had an opportunity, about 
eight months afterwards, of examining the condition of the part on 
dissection, the patient having eventually died of phthisis pulmonalis. 



CANCER OF THE UTERUS. 767 

There was considerable loss of substance, but the cicatrization was 
complete, and there was no surrounding hardness. 



VASCULAR SARCOMA, SCIRRHUS AND CANCER OF THE UTERUS. 

By vascular sarcoma of the uterus, I mean an increased growth 
of that organ, by a deposition of organized matter similar to its na- 
tural structure, and possessing its fibrous appearance. In all the 
cases which I have seen, the disease seemed to advance with symp- 
toms showing increased action, if not inflammation itself — such as 
general febrile movement ; pain increased on pressure ; general 
tenderness of the part ; tumefaction of the abdomen, which has been 
always observed to be more and more enlarged after the subsidence 
of every attack. These symptoms recur at irregular periods, with 
intervals of one, two or more months. The natural functions do not 
appear to be much disturbed, except during the inflammatory parox- 
ysms ; in general, the appetite is good, but there is much thirst ; diges- 
tion goes on well, at least for a considerable period, and the bowels 
are not more impeded than can be well accounted for by the mecha- 
nical pressure; the stools generally have a natural appearance; and 
the menstrual discharge, in many, continues to flow, but sometimes in 
increased quantity, so as to resemble active haemorrhage. The uterus 
sometimes grows to an immense size, if the disease advances slowly. 
I once had an interesting case of this affection under my care, in 
which, upon dissection, the uterus weighed about fifty pounds avoir- 
dupois, which is, perhaps, the most extreme instance on record, par- 
ticularly in which life was preserved so long. The tumour not only 
filled the abdomen, but pushed the diaphragm so high, that it en- 
croached upon the thorax, and lay over the heart and lungs, so as to 
conceal the respiratory sound over the whole anterior part of the 
chest. So high did it reach, that the diaphragm on the right side came 
in contact with the first rib ; the lungs were found reduced to about 
a third of their natural size; and although the heart was, perhaps, 
rather, target than natural, it was flattened by the pressure it had 
sustained. A cast of the body of this person, a preparation of the 
uterus and several drawings are in my museum. 

On cutting into an uterus, affected with vascular sarcoma, there is 
observed not only a resemblance to tbe natural structure, but an ab- 
sence of those white lines which characterize scirrhus; and there is 
nothing like ulceration. The disease has no resemblance to tuber- 
cles of the uterus, which are circumscribed and seem like knobs 
projecting from its surface, OI embedded in its substance. Iii vascular 
>ma, it is impossible to point out where the proper structure of 
the uterus terminates, <>r the diseased structure commences; the sur- 
face Ol tbe Organ is generally even, and wants the hard, indurated 

feel of wirrhus. Womi d affected with this disease may die at last 
from the effect of peritonitis, phthisis pulmonalis, or of some cerebral 
affection, instances of all of which I have known; and in some cases 
the uterus has been found, apou dissection, very much enlarged from 

tins disease, where little, and, in others, no suspicion was entertained 



768 DISEASES OF THE UTERUS. 

of organic disease. This, I apprehend, can scarcely happen in scir- 
rhus or cancer. 

Treatment of vascular sarcoma of the vterus. — In the gravid 
condition of the uterus, fresh matter is deposited by its arteries, so as 
to increase its bulk and weight in a remarkable manner, but is again 
absorbed after delivery; and from the analogy which exists between 
vascular sarcoma and the great increase in the substance of the 
uterus during gravidity, it is probable that the preparations of iodine, 
by exciting the action of the absorbent system, will be found suc- 
cessful in its treatment. The iodine may be exhibited either in the 
form of tincture or combined with potash, forming the hydriodate of 
potash; of the former, ten drops may be given three times a day, 
gradually increasing the dose to thirty — of the ordinary solution of 
the latter, thirty drops increased to sixty; and either of these pre- 
parations may also be applied externally in the form of ointment. I 
have never seen any of the bad consequences from the use of iodine 
concerning which so much has been written, except in one case, and 
I have employed it very frequently, and continued it for months. 
The application of leeches — contra-irritation in the pelvic region— a 
rigidly abstemious and dry diet — careful attention to the bowels — 
and the avoiding exercise, particularly towards the menstrual periods, 
are all collateral means which are highly necessary, and must not be 
neglected. I cannot too strongly urge the advantage of applying 
the leeches to the cervix of the uterus. 

I cannot resist stating the effects of the above-mentioned treatment 
in the case of a lady, who, after having for some months observed a 
tumour the size of the bottom of a Florence flask, above the brim of 
the pelvis, rapidly increasing both in size and weight, and bearing 
down in the passages — mentioned her situation to her friends, who 
advised medical assistance to be called, which was done accordingly. 
After a large quantity of iodine had been used without any effect, I 
was consulted, and found an enlargement, not only above the brim of 
the pelvis, but also filling up its cavity, producing constipation and 
micturition from the pressure upon the rectum and bladder. I gave 
an unfavourable opinion, but added that there was a possibility of 
checking the activity of the disease, and the further enlargement of 
the tumour, at least for some years. There never was a case which 
better illustrated the advantages of the combined influence of the 
treatment already mentioned: leeches and contra-irritation were em- 
ployed in addition to the external and internal use of iodine ; an im- 
mediate effect upon the activity of the disease was observed, and 
from this time the tumour began to diminish. When I first saw her, 
she was the size of a woman in the fifth month of pregnancy. In the 
course of three months the tumour could not be felt by external ex- 
amination, and at the termination of seven, the treatment was dis- 
continued, as she ceased to feel any inconvenience, except a slight 
degree of weight in the passages. I have had an opportunity of 
seeing this patient many times since, and am assured that she feels 
nothing of her former disease, and that she menstruates regularly. 
No examination of the parts has been made since the treatment was 



CANCER OF THE UTERUS. 769 

discontinued, at which time, however, the uterus was found much 
reduced in size. 

There are two interesting cases, showing the success of the iodine 
treatment in uterine tumours, published by Dr. Baron, and respecting 
which I find an article in the Med. Chirurg. Review for August, 1S29. 



SCIRRHUS AND CANCER OF THE UTERUS. 

As these affections are so frequently combined, and as scirrhus so 
often terminates in open cancer, I shall treat of them together ; al- 
though I am aware that one species of cancerous ulceration may take 
place from the immediate effects of inflammatory action of the parts, 
without the intermediate condition of the scirrhous degeneration. 
These are diseases which generally show themselves about the 
period when menstruation ceases in the course of nature, while vas- 
cular sarcoma usually affects those who are younger; but the most 
active cancer may occur in females under thirty years of age, several 
fatal cases of which I have myself attended. Women seem to be more 
liable than men to scirrhus and cancer, which are the most dreadful 
and intractable diseases to which they are subject. It is generally 
believed that the disease first commences in the cervix of the uterus. 
At first there is a slight uneasiness in the part with glairy discharge, 
and a sensation, attributed to weakness or weariness, in the lumbar 
region ; in the course of some time, heat and itching about the vagina 
take place, with thirst, some degree of fever during the night, and 
increased discharge, which at this period is slightly discoloured, hav- 
ing rather a disagreeable odour; these two last circumstances are the 
first to create alarm, and induce the patient to seek for medical ad- 
vice. As the disease advances, the pain becomes more severe, burn- 
ing and stinging; the discharge more and more foul and fetid, some- 
times alternating, however, with large evacuations of a limpid , serous 
fluid ; the palms of the hands and soles of the feet feel as if scorched, 
with great restlessness and thirst, particularly during the night. The 
stomach becomes at times very irritable, so that nothing can restrain 
the tendency to vomit; the pulse is rapid; the surface either harsli 
BBd dry, or bedewed with perspiration; and there is very frequently 
B deadly paleness, not only of the countenance, but affecting the whole 
body. Sometimes active hemorrhage takes place from the passages, 
winch no doubt proceeds from some vessels, the coats of which arc 
ulcerated. 

The ulceration is sometimes confined to the cervix and OS uteri 
and upper part of the vagina, at Others it extends to every part of the 
organ as well as the vagina, affecting, in some cases, the rectum and 
the bladder, through the coats of which it extends; but more fre- 
auentlythi involves the rectum. I have several preparations 

in my museum, where perforations are to be seen, not only between 
the rectnm and the vagina,bul also between the rectum and the uterus. 

The duration of the disease is very various; in some cases it runs 

through its course inbeft n two and three months; in other in- 

stances, when the scirrhous degeneration precedes the cancerous, the 



770 DISEASES OF THE UTERUS. 

course of the disease may occupy years. Sometimes the patient dies 
a lingering and painful death, the fatal termination being attributed 
to the gradual decay of strength, by the joint effects of the constitu- 
tional irritation, pain, want of sleep and inanition; at others, peri- 
tonitis takes place suddenly, and hurries the patient quickly to her 
grave. 

Treatment of scirrhus and cancer of the uterus. — It is to be 
apprehended that these degenerations have been too often allowed 
to run through their course, without sufficient means having been 
taken to subdue them or to arrest their progress, from the prevailing 
opinion of their utter hopelessness. But I am not singular in believ- 
ing that, although not, perhaps curable, much may be done to arrest 
their progress for many years, and at the same time to make the pa- 
tient comfortable, provided the disease be attacked early by the means 
now to be described, which I can strongly recommend from experi- 
ence. These are, a dry, abstemious, but sufficiently nourishing diet ; 
assiduous attention to the bowels, without producing purging or in- 
testinal irritation ; strict confinement to the horizontal posture upon 
the occurrence of the slightest pain, and allowing gentle exercise to 
be taken only when no pain has been complained of for some time, 
and when the weather is fine. The body must be protected by suf- 
ficient clothing, and precautions taken to prevent the possibility of 
the feet becoming cold. A flannel T bandage should be worn ; and 
upon the occurrence of the slightest pain, discharge or febrile move- 
ment, leeches are to be applied to the part affected, and repeated 
according to circumstances, followed by the production of contra- 
irritation, either by means of a blister to the sacrum or antimonial 
ointment to the lower part of the abdomen, together with the occa- 
sional use of the tepid bath. 

An examination per vaginam should be made from time to time, 
in order to ascertain the condition of the parts; and we are to form 
an opinion, along with the other circumstances mentioned, from the 
size and weight of the uterus, but particularly from the state of the 
os uteri. It is always a bad sign if it be found more and more gap- 
ing and ragged, and if increased pain and haemorrhage be produced 
by the touch. 

In the advanced stages of the disease, we are often implored to 
relieve the distress occasioned by the pain, intractable vomiting, 
restlessness and want of sleep; and sometimes, I am sorry to say, 
we are applied to in vain ; for the stomach is either too irritable to 
retain any medicine, or the opiate which is given produces in a few 
hours the irritability of the stomach, or creates a rending headache. 
Thus we are often placed in the most afflicting position, sometimes 
blamed for not being able to relieve the present sufferings of the 
patient, at others for having created, by our remedies, sensations 
which are less endurable than those for which they were prescribed, 
so that we are obliged to run through the whole list of narcotics. I 
have sometimes found one, sometimes another, serviceable in allay- 
ing pain ; but upon the whole, more benefit is derived from small 
doses of the sedative solution of opium thrown into the rectum, than 
from any other means. Care should be taken not to administer one 



CANCER OF THE UTERUS. 771 

single drop more than is necessary to subdue pain, because the small- 
est additional quantity will be quite sufficient to excite vomiting or 
violent headache. I generally begin, therefore, with from five to ten 
drops, gradually increasing the dose, as the system gets habituated 
to the remedy. Much comfort will be produced by the administra- 
tion of pills, containing equal parts of camphor and hyoscyamus, but 
more particularly when there is irritation of the bladder, or much 
nervous irritability. 

The sickness and vomiting are generally more difficult to allay than 
the pain. All known remedies have sometimes failed in my hands, 
but more success has followed the administration of a pill composed 
of two or three grains of calomel and two of opium, with a small 
blister, or a plaster composed of spices mixed with opium, applied to 
the epigastric region, than any other means. 

In all cases where the disease is far advanced, the patient suffers 
much loathsome feeling from the bad odour of the discharge, which, 
in many instances, excites or aggravates the irritability of the sto- 
mach ; and it often requires a strong sense of duty or great affection 
to sit long at the bed-side. It therefore becomes a very important 
object to remedy this evil, which we can now do most effectually by 
throwing injections into the passages containing the chloruret of lime 
or of soda properly diluted with water, and repeated several times 
during the day, as well as by sprinkling these substances over the 
room and bed. 



CHAPTER X. 



PROLAPSUS OF THE UTERUS— RETROVERSION OF THE 
UTERUS— POLYPUS OF THE VAGINA AND UTERUS. 



PROLAPSUS OF THE UTERUS. 

This affection may exist in various degrees, from the slightest re- 
laxation to the complete expulsion of the uterus beyond the external 
parts, when the disease is termed Procidentia. The slighter forms 
of this disease are not easily discovered; but when it exists in a 
greater degree, a sense of weariness and pain in the back is com- 
plained of, together with a dragging sensation; the patient feels as 
if something were protruding from the external parts ; and there is 
usually some discharge like leucorrhcea. As the disease advances, 
the bladder, from its connection with the vagina and uterus, becomes 
affected and displaced, micturition is produced, and sometimes stran- 
gury. It should also be recollected, that the more the uterus is pro- 
truded, in the same ratio must the vagina be everted. It is generally 
remarked, that should a woman affected with prolapsus of the uterus 
become pregnant, the uterus, instead of being pressed lower down 
by its increased weight, rises in the abdomen as usual ; so that it is 
more difficult to feet the os uteri at the seventh month, than in the 
unimpregnated state ; but I have seen several cases where the dis- 
ease became aggravated as pregnancy advanced. 

Causes of prolapsus of the uterus. — The chief cause of this dis- 
ease is getting up too soon after delivery, or even sitting up in the 
half erect posture, before the uterus is reduced in size; but I have 
known the affection to be very troublesome in the virgin state in re- 
laxed habits. Constipation and bearing down efforts, together with 
lifting heavy weights, and using any exertion during the time of the 
menstrual discharge, are also causes of prolapsus. 

Treatment of prolapsus of the uterus. — The horizontal posture, 
avoiding every exertion, and keeping the bowels open, are the chief 
means to be recommended, together with the daily use of cold water 
to the parts, and an astringent injection, composed either of the sul- 
phates of alumina, zinc, lime-water or a decoction of oak-bark. In 
extreme cases, an instrument called a pessary is to be introduced 
into the vagina, in order to support the parts. 

Should the uterus be found already protruded beyond the external 
parts, in the state called Procidentia, it is often possible to produce 



RETROVERSION OF THE UTERUS. 773 

reduction by attention to the bowels, after persisting in the horizon- 
tal posture for several days, and by employing long-continued pres- 
sure with the hand on the protruded part, so as to deprive it of blood; 
after the uterus is pushed within the parts, it must be retained by a 
pessary and a T bandage. 



RETROVERSION OF THE UTERUS. 

This is a complaint which takes place in the first months of preg- 
nancy, and in which the fundus of the gravid uterus is tilted back- 
wards out of its natural situation, and becomes wedged under the 
great promontory of the sacrum, the os uteri projecting toward the 
symphysis of the pubis, where it frequently presses upon the urethra 
or neck of the bladder, as does the fundus of the uterus upon the rec- 
tum as it passes down along the sacrum. The symptoms are more 
or less violent, consisting of bearing-down pains with uneasiness, 
feeling of weight in the passage and pain in the belly, partly, per- 
haps, from distension of the intestine, but principally from disten- 
sion of the bladder, which may be felt over the brim of the pelvis. 
Generally, no urine is passed from the bladder, and, although there 
is frequent desire, no satisfactory evacuations take place from the 
bowels. There are usually febrile symptoms and considerable rest- 
lessness. 

Causes of retroversion of the uterus. — Although it is a disease of 
pregnancy, yet I have known it to take place in the unimpregnated 
state; but in which cases the uterus was rendered pretematurally 
large by menstrual obstruction. Constipation and distension of the 
bladder coexisting, is the chief cause of retroversion of the uterus, 
assisted, perhaps, at the moment, by some unusual exertion or efforts 
when at stool. 

Treatment of retroversion of the uterus. — I have seen some very 
curious, but unpardonable mistakes made by practitioners not being 
able to detect this complaint. If once recognized, which it can only 
be by examination made in both passages, the treatment is simple, 
and generally very satisfactory. The chief points to be attended to 
are, to evacuate the contents of the bladder and the rectum ; the first 
is easily effected by the introduction of the catheter; but it should be 
known and remembered, that the more the female bladder is dis- 
tended, the more does the urethra become elongated, so much so, 
that I am aware of the particulars of a case that terminated fatally, 
owing to the embarrassment occasioned by this circumstance, and in 
which the ordinary female catheter did not reach the bladder; this 
created a belief that it was empty ami threw the practitioners off 
their miard. Upon dissection, the bladder was (bond enormously 

distended, producing peritoneal inflammation, which was ib«' cause 
0! death. The uteres vras found, between the third and fourth month 
of pregnancy, in ;i retfOVerted stale. The actual preparation of the 
bladder and literal and a drawing <>(' the relative situation of pails, 

by tin: master-hand "i Sii Chai les Bell, an: in my museum. 

Considerable address is sometimes required, after the contents of 



774 POLYPUS OF THE VAGINA AND UTERUS. 

the bladder are discharged, to clear out the intestines. Castor oil 
should be given, and some hours afterwards, an injection of tepid 
water should be thrown into the bowels; but the rectum is so tender, 
and the obstruction so great, from the pressure of the fundus of the 
uterus, that this simple operation cannot be trusted to ordinary hands; 
it must, therefore, be done by the practitioner himself, in the follow- 
ing manner: The patient being placed upon her knees, leaning for- 
ward, the pipe, well greased, is to be slowly introduced, with the 
point properly directed along the hollow of the sacrum, when the 
fluid is to be gradually thrown in. In former days, attempts were 
made to place the parts in situ, by introducing two fingers into the 
rectum, and forcibly pressing forward the fundus of the uterus; but 
this practice is now seldom employed, at least for some days, and 
practitioners in the mean time content themselves with keeping the 
bowels open, and relieving the bladder. Fomentations are serviceable 
in relieving pain, as are opiates, after the bowels have been freely 
opened. General bleeding may sometimes, though rarely, be neces- 
sary; but it is at least safe practice to draw blood, if there be much 
pain in the abdomen and pelvis, with tenderness to the touch, and 
particularly if the pulse be full and hard. It must not be forgotten 
that abortion may take place, which is to be managed in the usual 
manner; and, as far as I know, there is only one case on record, 
which occurred to Dr. Merriman, where there is good evidence of 
the uterus in this situation carrying on its contents to the full period. 



POLYPOUS TUMOURS OF THE VAGINA AND UTERUS. 

Tumours of this class are often met with in practice ; for the most 
part, their structure is hard, and they are covered by an elongation 
of the mucous membrane of the part from whence they have arisen; 
sometimes, although rarely, they are soft and lymphatic, resembling 
those found in the nose. No age is exempt from them, although they 
are not so frequently met with in very young subjects. Sometimes 
they are found attached to the vagina, but generally spring from 
some part of the uterus, and may be attached either by a broad base 
or by a narrow pedicle; but the latter is the most common, particu- 
larly after the tumour has been expelled from the uterus. Uterine 
polypi may grow from any part of the uterus, of which some fine 
examples may be seen in my museum, in one of which, a small 
tumour of this description, of a bright red colour, is seen projecting 
from the Fallopian tube. Most generally, however, polypi arise 
from the cervix uteri. 

The constitutional symptoms are similar to those produced by other 
diseases of the uterine system. These are, loss of general health and 
strength, dyspeptic symptoms and irregularity of bowels. When 
uneasiness and a dragging sensation low down in the back, with 
bearing-down pains and micturition are complained of, particularly 
if attended by discharge, some suspicion of uterine disease is natu- 
rally excited; but it is only by an examination that the nature of it 
can be detected, and then only when the tumour is either totally or 



POLYPUS OF THE VAGINA AND UTERUS. 775 

partially expelled through the os uteri; considerable mystery will 
otherwise hang over the nature of the disease. The discharge is 
at first mucous, subsequently it becomes tinged, and at last alto- 
gether bloody ; the bleeding is at times copious, and is supposed to 
proceed from the rupture of considerable-sized veins. As soon as 
a polypous tumour in the uterus gains some degree of size, its 
mechanical pressure produces a sense of weight and uneasiness in 
the passages, even should it be situated in the vagina; — but if in 
th»:! uterus, there will be frecpuent, and sometimes severe pain, 
which, although partly owing to the same cause, is to be principally 
attributed to contractions of the uterus, which have all the charac- 
ters of those observed during abortion in the early stages of preg- 
nancy. In such circumstances, the discharge is considerable, which, 
together with the constant paroxysms of pain, want of rest, failure 
of the appetite, &C., weaken the patient; hectic fever will ensue, and 
the patient may die from the etlects of long-continued constitutional 
irritation, or from exsanguinity or debility. The tumours are said 
sometimes to ulcerate, and to send forth excrescences ; but of this I 
have not seen any example. On examination with the finger, it is 
of great moment to be able to distinguish between diil'erent diseases 
which resemble polypus, particularly prolapsus and retroversion- of 
the uterus, and perhaps also steatomatous tumours, which are some- 
times formed between the rectum and vagina. A polypus is, in 
general, not tender to the touch, although it must be remembered 
that the vagina^ which embraces it, may be in that state ; the depend- 
ing part is generally the largest, at the extremity of which nothing 
in OS uteri can be felt. Upon tracing with the finger for the 
origin of the tumour, we shall either come to its attachment in the 
vagina, and distinguish the uterus higher up, or if it should spring 
from the uterus, we shall be able to detect the os uteri encircling 
it like a ring; and, in order to prevent any chance of mistake, 
we should make a point of tracing the whole circle which the 
os uteri makes. I can scarcely fancy how retroversion of the 
uterus can l.e mistaken for this affection, because, in that case, the 
uterus will he tender to the touch, and the us uteri discovered pro- 
jecting towards the symphysis of the pubis, with the fundus directed 
towards tin.- hollow of the sacrum. Tumours situated in the recto- 
be easily distinguished by making an examina- 
tion by ill'; rectum, as well as the vagina. I have heard of one case 
which occurred in Loudon, and which made a considerable noise at 

the tune, where an eminent surgeon most uuaeeoiuitably mistook a 

relaxed and prolapsed Madder for a polypous tumour, and il was 

with great difficulty ho was restrained from applying a ligature. 

a in the profession, whether physician or Burgeon, should 

be able to distinguish betw n such diseases by the usual mode of 

aination, although il may he well, before proceeding to any ope- 
ration, to i.e sanctioned by the authority of an accoucheur. The ne- 

ity of medical men directing their attention to the diseases of the 
uterine system in a proper manner, is well illustrated by the milow- 
ing case : — A young woman, aged 85, a widow, and the mother ol 
two children, v. i upon by DM lor polypus in the winter "I 



776 POLYPUS OF THE VAGINA AND UTERUS. 

1825. This woman's complaints had continued for two years, dur- 
ing which time she had been affected with increasing pain in her 
back and loins, frequent desire to make water, and a leucorrhoeal 
discharge, with frequent haemorrhage, which created great debility. 
The functions of the stomach became affected early in the disease, 
and the bowels were sometimes constipated, sometimes too loose. 
For some months she complained of cough, attended by expectora- 
tion, which was sometimes bloody. She had taken every remedy 
in the pharmacopoeia to restrain the haemorrhage, and had been fre- 
quently bled upon the same principle that venesection is had recourse 
to in epistaxis, but, as might be expected, without any benefit. At 
this juncture she fortunately consulted Dr. Duffin, now of London, 
who was led to make an examination, when he discovered the pre- 
sence of a polypus. I was consulted, and immediately performed 
the operation, by including the tumour within a ligature in Dr. Duf- 
fin's presence. The tumour separated on the fourteenth day, and 
was found to have a very broad base. Leeches were applied to the 
abdomen several times before the tumour dropped off, in consequence 
of symptoms denoting peritoneal inflammation ; but the woman made 
a good recovery, menstruated soon after, all the unpleasant symp- 
toms quickly vanished, and she has ever since enjoyed excellent 
health. 

Treatment of polypus. — The sooner a ligature is applied the bet- 
ter, and there is no operation more easily performed, if the double 
canula of Levret be used, the tubes of which instrument may be 
separated at pleasure. A hempen ligature well waxed is preferable 
to a silver wire, which, on one occasion, after I had applied it, gave 
way on the eighth day, and required to be renewed. The ligature 
should, in general, be made tight from the first, but should there be 
much pain experienced in attempting to do so, the pressure had bet- 
ter be produced very gradually. Before the operation, the bowels 
should be brought into a proper state ; and after the application of 
the ligature, the patient should be watched, in order that any inflam- 
matory action, either of the uterus or peritoneum, may be speedily 
attacked, and subdued by venesection or leeching. Opiates are also 
serviceable to allay pain and produce sleep. 



CHAPTER XL 

TUBERCLES OF THE UTERUS— BONY CONCRETIONS— 
HYDATIDS— AQUEOUS AND FLATULENT DISCHARGES. 



TUBERCLES OF THE UTERUS. 



The diseased formation which generally bears this name is not 
the scrofulous tubercle which is so frequently found in the I lings, 
mesentery aud almost all other tissues of the body. The tubercles 
of the uterus are hard, somewhat spherical-shaped masses, sometimes 
imbedded in the centre of the substance of the uterus— projecting 
into its cavity — or from its external surface; in the one case, the pro- 
jecting part is covered by the mucous membrane, in the other by 
the peritoneum. They have also other characters which distinguish 
them from the scrofulous tubercle, being fleshy and more or less 
vascular, whereas the others have not the slightest cameous appear- 
ance ; and I have never been able, even after minute injection, to see 
a single vessel in their substance. Suppuration is unknown, and 
ulceration rarely takes place. There is as much doubt, however, 
respecting the pathology of tubercles of the uterus as of those which 
arc found in the Innga Some suppose it to be a disease of the cel- 
lular substance; while others allege it depends upon that of the 
proper muscular fibres of the uterus; and there are many who attri- 
bute tins diseased formation to inflammatory action. On making 
sections in a great number of cases of tubercles of the uterus, I find 
that some consist of a hard cartilaginous shell, containing an almost 
transparent thud; others are Bemi-cartilaginous throughout, and show 
white shining lines running like radicles in every direction, intersect- 
ing each other, the interstices apparently containing the proper sub- 
stance of tbeuterue; some appear to be minute vesicles, or small 
containing a fluid, occasionally giving somewhat of a honeycomb 
appearance; other tubercles approach very near to the nature of bone; 

while a lew hear an exact resemblance, in every respect, to the proper 

substance of the uterus. These tubercles are found of various Bizes, 
from that of a ; . and even larger; they may be 

eiibei solitary or exist in considerable numbers, so as to enoroach 
upon the cavity of the abdomen, and occasionally give to the uterus 
otesque appearance, making its cavity, from the os uteri n> the 
fundus-, long and winding, in other instances obliterating the cavity 
of the uterus. 



778 BONY CONCRETIONS. 

The symptoms produced by tubercles of the uterus depend very 
much upon their character and size; generally speaking, they are not 
of a malignant nature, and if so, few or no constitutional symptoms 
will arise, at least for a considerable period of time. But if malig- 
nant, the symptoms will resemble those of scirrhus and cancer; 
when large, they produce mechanical pressure upon neighbouring 
parts, and give rise to corresponding symptoms, both local and con- 
stitutional. The local symptoms are tenesmus, constipation, desire 
to make water, and pain in making it, weight and bearing down in 
the passages. Menstruation is regular, at least in most cases; but 
occasionally the performance of this function is attended with diffi- 
culty and pain; in several instances, where the state of parts was 
afterwards ascertained by dissection, menstruation was observed 
to be more copious than usual, with shorter intervals between the 
periods. 

Treatment of tubercles. — Little more can be done than to palliate 
symptoms as they arise, prevent constipation and mitigate irritation 
of the bladder and uterus, should it exist. 



BONY CONCRETIONS. 

Bony or earthy concretions in the uterus are by no means rare ; 
several undoubted specimens of which are in my museum. They 
are of different sizes, and exist, as far as I am aware, solitary; their 
surface is generally rough, being intersected with fissures and indent- 
ations; they are commonly more or less of a spherical shape; and 
the presence of such bodies in the uterus may be expected to give 
rise to general and local irritation. In one case, a substance of this 
sort was found after death in the uterus of a woman who had 
been long subject to uterine irritation and hysteria, and who at 
last fell a victim to phthisis pulmonalis. Another woman, after hav- 
ing been delivered of a healthy child, appeared to be doing well for 
twenty-four hours, when pains like those of a second labour took 
place, which induced a belief that a twin was coming into the world; 
this however was not the case ; something hard was felt passing 
through the os uteri, which, in the course of a few hours, was ex- 
pelled during a violent paroxysm of pain, and was found to be a cal- 
culus of the description now under consideration : the woman did 
well, and had no return of the complaint. Another preparation about 
the size of a turkey's egg has been lately presented to me by a me- 
dical friend in Stirlingshire, with the following history: An unmar- 
ried woman consulted him about a uterine affection, attended with 
enlargement of the abdomen and other symptoms which led him to 
suspect that she might be pregnant, the possibility of which she ad- 
mitted. At the termination of a year, or somewhat more, she actu- 
ally entered into the holy state of matrimony, and became, in the 
course of time, "as women wish to be who love their lords." She 
went on to the full period; strong uterine action came on; a hard, 
unyielding substance was felt at the os uteri, which was expelled 



HYDATIDS. 779 

before the child, and was found to be the calculus sent to me. The 
child was born alive, and the woman made a good recovery. 

In some instances, the substance of the uterus itself is converted 
into calcareous or bony matter. — Two splendid specimens of this 
kind were lately presented to my museum; one came from a subject 
in the anatomical rooms, the other from Dr. Grieve, of Dumfries, and 
was found in an aged person who fell a victim to cholera. In these 
preparations the osseous deposit is dispersed here and there in the 
uterus, which, in both cases, is considerably enlarged and indurated. 

Considerable dubiety must always exist in such cases ; the calculus 
can only be discovered by introducing the finger or a sound into the 
os uteri ; but even from such an examination we shall possibly de- 
rive little additional light, as it must not be supposed that the calcu- 
lus, when touched with the sound, will produce the same sensations 
as those emitted on touching a stone in the bladder, uterine calculi 
being coated with a thin layer of a substance as soft as boiled carti- 
lage. 

Treatment. — We have to allay general and local irritation as in 
other uterine diseases. Mr. Burns has given references to several 
interesting cases of this kind, and, among others, to a case mentioned 
by Gaubius, where the affection was complicated with a prolapsed 
state of the uterus. After a considerable time a large stone was 
expelled by violent action of the uterus. On the next day a larger 
stone presented at the os uteri, which gradually dilated, and allowed 
it also to pass ; and he states, that smaller stones were extracted from 
time to time, and the patient gradually got well. In the 1st volume 
of Le Journal des Sava?is, a case is related by Beale, in which an 
incision was made into the uterus of a woman, and a calculus ex- 
tracted, which had existed for eight or nine years with insufferable 
pain, after which she recovered. At first the concretion weighed 
nearly 4 oz., but after it was dried it became very light for its size. 
Mr. Burns also tells us of a case of calculus occurring in a child of 
five years of age, who died in consequence of suppression of urine.* 



HYDATIDS. 

Hydatids are sometimes formed in the uterus; occasionally they 
are solitary, but for the most part are very numerous, being of vari- 
ous sizes, from that of small currants upwards, and attached to each 
other by a loose cellular-looking substance, which is probably coagu- 
lated lymph. The nature of these substances is not known, and the 
prevailing Opinion thai they arc produced by blighted conceptions, 
I cannot believe to be correct. The symptoms are such as are occa- 
sioned by any other cause of uterine irritation, and are accompanied 
by uterine efforts resembling labour-pains, [f the true nature of the 
complaint were detected, which it can only be by a partial discharge 
of hydatids, 't might be serviceable to introduce an instrument like a 
sound into the uterus, lor the purpose of breaking them down, and 

♦ In ■ late diBMCtfoO of an n<,'cil woman win. died Of cholera, the arteries of the 
uterus were ossihed. The organ luelf was in a state of extreme atrophy, 



780 AQUEOUS AND FLATULENT DISCHARGES. 

loosening any adhesions which may exist between them and the ute- 
rus, and afterwards to exhibit an infusion of the ergot of rye, made 
with two drachms of that substance in four ounces of water, which 
from the violent uterine action it induces in certain cases of lingering 
labour, I would expect to be very effectual in causing the expulsion 
of hydatids. It must be understood, however, that I merely speak 
from analogy; and it must be remembered also, that while this re- 
medy will be, at least, innocent in the case of hydatids or any other 
soft substance contained in the uterine cavity, it might be fatal if 
used to produce the expulsion of a bony concretion. Local and con- 
stitutional irritation must be relieved by the means already recom- 
mended, and after the discharge of the hydatids has taken place, 
every measure must be used to re-establish the general health. 



AQUEOUS AND FLATULENT DISCHARGES. 

Both of these affections, but particularly the first, frequently at- 
tend hydatids, as also scirrhous and cancerous affections of the uterus 
and vagina, and more particularly the cauliflower excrescence. I 
was lately consulted about a young married woman, the mother of 
three children, respecting a very copious discharge of watery fluid 
which took place from the vagina, alternating with leucorrhoea: she 
menstruated regularly, and during these times the aqueous discharge 
did not take place. On examination I found the uterus rather bulky, 
and there were several small tubercles on one of the lips of the 
os uteri, but neither pain on pressing it nor gaping of its lips ; the 
vagina felt much relaxed. In this case, there were considerable 
flabbiness of person and weakness of habit, which I attempted to 
improve; but as I could neither persuade the lady to take medicines, 
nor, in fact, to do any thing she was desired, I gave up attending; 
and have no doubt, that in the course of time a scirrhous affection of 
the uterus will take place, the seeds of which already exist, but which 
might have been warded off by proper treatment. 

The discharge of flatus from the vagina I have most frequently 
remarked soon after delivery; it speedily wears off, and rarely con- 
tinues to be a source of annoyance beyond a week or ten days. 
This affection very seldom presents itself in other states of the sys- 
tem, but cases have been known to occur. I have heard of two 
instances where ladies have been obliged, in consequence of irregu- 
lar and loud explosions entirely beyond their control, to seclude them- 
selves from society — an unnecessary restraint, because such occur- 
rences may be prevented by wearing a small canula in the passages. 

In the flatulent as well as in the aqueous discharge, which does 
not depend on cancer, the complaints, I conceive, may be altogether 
removed by means taken to improve and invigorate the general 
health — such as proper regimen, cold or warm bathing, and atten- 
tion to the bowels. Considerable benefit will also be derived from 
throwing astringent injections into the passages twice or thrice a day. 



CHAPTER XII. 
FLUOR ALBUS AND LEUCORRHCEA. 



Considerable difference of opinion exists in the minds of the pro- 
fession respecting the application of these terms : — some use them 
synonymously, others apply the term fiuor albns to designate the ex- 
istence of a white discharge from the passages, which is unattended 
by any marked constitutional symptoms, and which they suppose to 
proceed from the vessels of the vagina. They give the name of 
leucorrhcea to the discharge when it is opaque, and when the general 
health is much involved; in which circumstances they conceive the 
secretion comes from the uterus itself. 

The mucous membrane lining the uterus and vagina is constantly 
bedewed with a mucus secreted by its vessels, which, in the healthy 
state of parts, is merely sufficient to keep the surface moist; but it very 
frequently happens, from various causes, that this fluid is poured 
out in a superabundant quantity, which is then discharged from 
the passages, and has commonly obtained the name of " whites." 
It allects females of all ages, and frequently attacks even infants. It 
is a disease respecting which medical men are seldom consulted, 
unless the patient sutler pain, or the discharge be excessive, occa- 
sioning general debility and, perhaps, producing excoriation of the 
parts. 

Considering the one to be an advanced stage of the other, I shall 
treat of both under the general term leucorrhcea, without reference 
to the colour, quantity, or Beat of the discharge. 

Symptom* qf leucorrhoea.— Patients, for the most part, complain 
of a sense of weakness, weight, and often severe pain in the back, 
attended by a discharge of glairy, transparent mucus in considerable 
quantity, having the appearance of new made thin starch, which, 
however, sometimes looks milky and opaque. The discharge and 
constant pain, sooner or later, produce debility and impaired health; 
the functions of tin; Btomach and bowels become impeded, the abdo- 
men full, often BlUCfa distended by flatulence; the countenance in time 
admins a peie and pasty appearance; the lips lose their colour; the 
eyes their natural brilliancy; the extremities are cold during the day, 
and for some time after retiring Id bed, when slight fever takes place, 

and they become burning with heat Sooner er later, if the disease 

be ii"t checked, palpitations occur, and the legs become anasareous. 
The brad also sull'-rs ill most instances, the patient Complaining of 
headache, and occasionally of vertigo. 



782 LEUOORRHCEA. 

These symptoms do not succeed each other rapidly in women of 
strong constitutions, in whom it usually takes a course of years; but 
in weakly habits, the disease is more rapid and severe in its con- 
sequences. The menses continue to flow very regularly in slight 
cases; and at these times the leucorrhoea generally disappears and 
returns again as soon as the period is completed. Occasionally, the 
menstrual discharge is much increased in quantity, and is irregular 
in its periods ; it also often happens that obstructions take place, and 
at the monthly times when a woman should be " unwell," the leu- 
corrhoea is found greatly increased in quantity, and accompanied by 
more severe pains in the back and loins. 

In addition to what has been above mentioned respecting the dis- 
charge, it may be stated, that it has sometimes a purulent appear- 
ance, and is occasionally tinged with blood ; but when this happens, 
or when it becomes fetid, considerable apprehensions may be enter- 
tained respecting the condition of the uterus. In all cases of discharge, 
an examination per vaginam is absolutely necessary. 

Causes of leucorrhoea. — Leucorrhoea often takes place in full, ple- 
thoric habits, and in women who are much exposed to heat; it may 
also occur in weak, emaciated subjects ; and in both circumstances, 
may sometimes depend on increased action of the secreting vessels, 
approaching, perhaps, to inflammation. It may also be produced by 
causes which tend to weaken the action of these vessels, as frequent 
abortions, excessive venery, and long-continued exposure to cold 
and fatigue. It may be also occasioned by the presence of ascarides 
in the rectum— by polypus, prolapsus and other affections of the 
uterine system— and also by scirrhus and cancer, which may be sus- 
pected if the person be beyond the meridian of life, and the discharge 
excessive, tinged or fetid. Some constitutions are more prone to be 
affected in this manner than others ; I cannot, however, point out 
any particular temperament or personal appearance which marks 
the susceptibility; but women are more frequently affected during 
pregnancy than at other periods, which may be well accounted for 
from the increased determination of blood to these parts. There 
can be no doubt that the unnatural, but, as it has been termed, re- 
fined manner of bringing up females in this country also predisposes 
to it. 

Treatment of leucorrhoea. — In all severe and suspicious cases, 
the practitioner should take an early opportunity of examining the 
state of parts, in order to be satisfied whether or not the discharge 
depends on organic disease ; for if it do, he cannot confidently pro- 
mise success from any remedial agents he may employ. Few dis- 
eases connected with discharges, from whatever part of the body 
they may proceed, should be hastily and rashly suppressed, or 
treated in any other manner than as constitutional affections. In 
leucorrhoea the remedies must be applied to the general system first, 
and not to the parts themselves, as if it were of local origin ; the 
constitution, in fact, must be prepared, in the first instance, to do 
without the discharge. 

However young and plethoric the patient may be, 1 cannot fancy 
a case which will require venesection, unless there be some unusual 



LEUCORRHCEA. 783 

circumstances attending it, as very violent pain and high constitu- 
tional excitement; but I have seen much advantage in weak, as 
well as in strong subjects, from applying leeches to the groins, when 
harassed with constant uneasiness in the uterine region: the number 
of leeches is regulated by the condition of the patient; — in some cases 
four will suffice, while in others a dozen may be required. But it 
may be hereafter found, that more decided advantage may follow 
the application of leeches to the os uteri. 

Plethora can be reduced much more effectually and permanently 
by a spare, dry, but sufficiently nourishing diet, and by acting upon 
the bowels, than by any other means. Regular but not violent ex- 
ercise should be recommended ; long walks are to be avoided, as 
well as every other cause which tends to produce fatigue. If the 
patient be weak, the diet should be more nourishing, the exercise 
less fatiguing, and wine may be allowed, or any other more palata- 
ble stimulant ; but the stomach must never be ovei*distended, and 
the use of slops should be entirely discountenanced. Should there 
be any evidence of the existence of worms in the rectum, the usual 
remedies, particularly turpentine injection, must be employed. After 
these steps have been pursued for some time, perhaps for a week 
or ten days, remedies may be used to suppress the leucorrhoea. 

The local remedies consist of different astringent injections thrown 
into the vagina, by means of an ordinary bag and pipe, or a womb 
syringe; these are composed of solutions of the sulphates of zinc, 
alumina, iron, copper, or the acetate of lead, or infusions of vegeta- 
ble astringents, such as green tea, oak bark or galls. They should 
be used at first weak, their strength being afterwards increased if 
necessary. 

It has been strongly recommended by many authors, to use oc- 
casional emetics; I have accordingly exhibited them, but without 
any apparent good effect. A gentle mercurial course, cicuta, can- 
tharides, the different resins and balsams, particularly copaiva and 
turpentine, have also been recommended, and are considered by 
some as specifics, together with cubebs and electricity, which is 
made to pass through the pelvic region. There can be no doubt that 
considerable benefit Iris been derived from the employment of each 
of these means, therefore one may be had recourse to after another; 
but, from my own observation, I may state that better effects have 
followed the use of the acetate of lead and the tincture of canthar- 
ides than of any other remedies. An occasional opiate is serviceable 
for allaying irritation and producing sleep. Women, particularly 
those in I inn ih I e stations, are very fond of having recourse to Strength- 
ening plasters; but tin; same end — viz., support to the back — may 
be effected by proper stays or a flannel bandage, without the dis- 
agreeable circumstances resulting from the plaster. Tomes have 
also been recommended, BS well as cold and warm bathing; to the 
occasional use of the former there can be no objection, and cold 
bathing in the open sea, at the proper season, is often serviceable in 

cases where then II no disease of the uterine system, and the patient 

not debilitated. 



784 LEUCORRHCEA. 

If the os and cervix uteri be found, upon examination, to be 
tender, swollen or doughy — if there be severe shooting pains in the 
pelvis or loins— and if the discharge be of a milky whiteness, then we 
must certainly have recourse to the internal application of leeches, 
and to the use of the warm hip-bath, which should precede all other 
remedies. 

Women who are liable to leucorrhcea should avoid violent exer- 
cise and exposure to extremes of heat or cold ; they should wear 
warm clothing, attend scrupulously to the state of their bowels, 
abstain from eating or drinking any article that is known to disa- 
gree with the stomach; and they should make a point of using the 
bidet twice a day. 



CHAPTER XIII. 
DISEASES OF MENSTRUATION. 



Under this head I shall treat of five diseased conditions of men- 
struation, which present themselves in practice. 

1. Amenorrhea, or obstruction of the menses. 

2. Dysmenorrhcea, or painful and difficult menstruation. 

3. Immoderate flow of the menses. 

4. Menorrhagia. 

5. Circumstances occasionally attending the cessation of the 
menses. 

AMENORRHEA. 

Under this denomination are generally included retention of the 
menses, and suppression; the former has also been termed emansio 
mensium, and implies that the discharge has not appeared at the 
usual period of life; the latter denotes that the discharge has become 
suppressed, which may occur in two circumstances to be afterwards 
mentioned. 

Retention of the menses. — This form of amenorrhoca becomes 
the subject of medical treatment only when a girl passes the usual 
period of life at which the discharge ought to occur, and when the 
constitution feels the want, which is evinced by the occurrence of a 
variety of symptoms, and the disorder of several functions. This 
time of life varies remarkably in different countries, occurring, it is 
believed, much earlier in hot than in cold regions; but even in the 
same climate, great differences are observed. The discharge ought 
to appear in connection with other signs denoting puberty; in tem- 
perate regions this happens about the age of fourteen ; but even in 
this country I have known several instances at nine years, bill a 
greater number in which the discharge had not appeared at eighteen. 

The usual signs which denote constitutional Buffering are the Id- 
lowing: — The patient loses her natural liveliness, forsakes her usual 
amusi-mmts, and even neglects necessary employments in which she 
ought to be engaged, sin: is restless, peevish, and feels incapable of 
exercising her mmd or fixing her attention; complains of weari- 
ness, lassitude and debility, and at the same time loses flesh. Il-r 
face becomes pale anil heT skin sallow; she has either DO appetite 

or experiences unnatural cravings to eat indigestible matter, which 

at other times creates disgust — such as cinders, lime, chalk and com- 
66 



786 AMENORRHEA. 

mon earth. When these symptoms have continued for some time, 
dropsical effusions occasionally take place, not only in the extremi- 
ties, but also in the abdomen, although the distension of the latter 
generally arises from flatulence, which occasions great uneasiness to 
the patient, sometimes even amounting to pain ; the belly becomes 
more swollen after meals, and particularly towards evening. The 
urine is either scanty or copious, and the bowels are torpid ; it is 
difficult to keep the extremities in a natural state of heat; and when 
the feet are cold, headache is generally complained of; indeed it fre- 
quently takes place, whatever may be the condition of the extremi- 
ties. Some patients become extremely apprehensive and anxious 
about their situation, while others have a melancholy appearance, 
and seem to care little about surrounding objects or themselves; and 
in some, anomalous hysterical affections appear. Cough and hurried 
respiration, if they have not already occurred, soon take place, toge- 
ther with expectoration. The bowels, which were formerly torpid, 
now, perhaps, become irritable and loose; at length the patient is 
affected with perpetual diarrhoea and hectic fever and dies greatly 
emaciated, sometimes with, at others without, any of the appear- 
ances of phthisis pulmonalis. 

This description is drawn from life, and is also an example of the 
disease called chlorosis, in its worst form. Chlorosis, however, is 
not peculiar to the female, as several exquisite cases have fallen 
under my notice in young men, about the age of puberty, and for 
the occurrence of which it is difficult to account; whereas, in women, 
it may be said to be excited by the want of a natural and periodical 
secretion. 

In this form of amenorrhcea, the symptoms sometimes take a dif- 
ferent course; cough and expectoration take place, with slow ema- 
ciation, the patient becoming better and worse for some years, the 
menstrual discharge, however, not appearing; and she dies at length 
of chronic phthisis, sometimes accompanied by ulceration of the 
bowels or of disease of the liver. Tubercles are occasionally found 
in most organs of the body, and the immediate cause of death may 
be chronic peritonitis. 

Causes of retention of the menses. — This form of amenorrhcea 
may depend, according to Mr. Burns and others, on a want of vigour 
in the system, by which not only a new action is prevented from 
being formed, but also those actions which were formerly performed 
become impaired ; or on a special want of energy in the uterus; but 
in far the greatest number of instances, menstruation is postponed 
merely from the general debility of the system. Absence of the 
menses depends, in some cases, upon a malformation of the organs of 
generation, as want of the ovaria, imperfect formation of the uterus 
or of the Fallopian tubes, cohesions of the vagina and labia, or an 
imperforated state of tl^e os uteri or of the hymen. 

Treatment of retention of the menses. — When a girl passes the 
usual period of life without menstruating, her friends naturally be- 
come anxious about her situation ; and this of course increases if 
her appearance denote loss of health, and more particularly should 
the symptoms be severe. When a medical man is called, his first 



AMENORRHEA. 787 

duty is to inquire into the cause of the retention; but his investiga- 
tions will be incomplete unless he make an examination, to ascertain 
if there be any malformation at the orifice, or in the course of the 
vagina, or at the os uteri. Notwithstanding this uncertainty, how- 
ever, delicacy forbids such an examination, at least for a time, till 
other means have been tried in vain, and life be likely to pay the 
forfeit. It is evident, also, that the want of the ovaria, or imperfect 
formation of the tubes, and, in some cases, even of the uterus itself, 
cannot be discovered by examination. 

The ureters may be perfectly well formed and healthy, but may 
want a certain something to enable it to commence the first of its 
peculiar functions. Now this certain something, of which we really 
know nothing, has been denominated want of energy of the uterus 
itself; and we judge of it by the health being as yet good, and the 
constitution strong and vigorous; although the pain, restlessness and 
other slight symptoms show that this will not be the case long, unless 
something be done by art. The humoral pathologists, influenced by 
their peculiar views, recommend opening a vein in one of the lower 
extremities; and it may be often serviceable. The best effects are 
sometimes produced in robust, plethoric habits, by taking a small 
quantity of blood at one, two, or three consecutive monthly periods: 
these monthly periods announce themselves every third or fourth 
week, by the aggravation of symptoms and increased suffering of 
the patient. Instead of general bleeding, however, I now prefer the 
application of six, eight, or more leeches to the region of the groin, 
or in the neighbourhood of the vulva, or, if admissible, to the os 
uteri itself. The discharge of blood relieves the system, and gives 
the uterus time to prepare for the office it has to perform, and pre- 
vents the general health from becoming affected ; while the discharge 
from that part of the body tends to excite some action in the uterus, 
which it is impossible to explain, and which may be produced either 
by unloading the vessels of the uterus, or by exciting a determina- 
tion of blood towards it and the other parts of generation. I am 
confident of the fact, although uncertain about the theory, having 
often observed the menstrual discharge appear out of its ordinary 
Bourse, upon the application of leeches to the pelvic region or abdo- 
men, when the attainment of no such object was in view. But on 
the other hand it ought also to be mentioned here, that monorrhagia 
is often checked by the same means, irhich shall be mentioned more 
at large when treating of that disease. A good deal of the benefit 
derived firom the application of leeches may be attributed to the 
effect of the bites produced upon the system at large. With respect 

to general and local bleeding, however, the strongest protest might 
be recorded against large and frequently repeated abstractions of 
blood from the system in this class of cases, It is the halm of some 
to take blood locally or generally upon every Blight occasion, and 
upon the occurrence of every headache, difficulty of breathing, and 
anomalous hysterical symptom, till patients cannoi pass a oreek with- 
out the operation, and at length the constitution becomes irretrieva- 
bly ruined. M called emmenago/fues, have I n long in 

use, but are now, for the most part, laid aside by practical men,who 



788 AMENORRHEA. 

agree that they are generally injurious. I cannot speak too highly, 
however, of the benefits to be expected from the use of cantharides 
in this and all other cases of diminished and obstructed menstrual 
discharge, commencing with doses often drops of the saturated tinc- 
ture three times a day, and gradually increasing the quantity to thirty, 
forty and even sixty drops. Care should be taken, however, to give 
proper directions that the remedy be immediately suspended upon 
the occurrence of any irritation in the bladder or urethra, when cam- 
phor and hyoscyamus should be exhibited, together with diluents, 
particularly linseed tea. 

Constipation is not only to be prevented, but the bowels are to be 
daily and freely acted upon by aloetic pills, conjoined with assafoetida, 
in case of pain from flatulent distension of the bowels. Aloes is pre- 
ferable in this case to any other purgative, because it appears chiefly 
to act upon the rectum; care must be taken, however, that irritation 
of the rectum is neither too much nor too long excited, lest it produce 
piles. The hip-bath is a powerful remedy in this class of cases, and 
is to be used daily ; it is preferable to the general hot bath, from the 
increased heat which partial immersion will enable a patient to sus- 
tain. At first the water should be somewhat under 100°, but the 
temperature should be afterwards increased by the addition of more 
hot water, till it is as warm as the patient can well bear. It is found 
beneficial to put an ounce of mustard in the bath. The clothing 
must, in all cases, be adapted to the constitution of the patient and 
the season of the year, and cold feet avoided. The patient should be 
much in the open air, taking such a degree of exercise as she can 
bear without fatigue ; the exercise must be regular, however; and 
riding on horseback is particularly serviceable, as well as the use of 
a swing. Agreeable society, and every thing which can amuse the 
mind, are to be enjoined, but crowded and hot rooms must be avoided. 
The diet should be regulated according to circumstances ;— if the 
patient be full and plethoric, it should be light, abstemious and dry ; 
— if weak, it should be more nourishing; but the stomach must never, 
on any account, be loaded. In neither case is the use of wine contra- 
indicated, unless there be fever or considerable local irritation. 

Cold bathing in the open sea often produces very unpleasant con- 
sequences in all forms of amenorrhoea, although it may certainly be 
serviceable in a few cases. It is a remedy too frequently had re- 
course to, particularly in Scotland, for every malady, and too often 
receives undue countenance from medical practitioners even of some 
degree of eminence. Frequently do I see cases of phthisis pulmon- 
alis, asthma, dropsy, diseases of the uterus, &c. which, if not produced, 
are certainly aggravated, by sea-bathing. I scarcely ever have oc- 
casion to ride along the sea-side without being grieved at seeing poor 
emaciated children, in the last stages of tabes mesenterica and other 
scrofulous affections, screaming and struggling while they are dipped. 
It may be mentioned once for all in this place, that when the system 
is much reduced, it cannot stand the abstraction of heat which is oc- 
casioned even by undressing in an exposed situation, such as a bath- 
ing machine, not to speak of that produced by complete immersion. 

External frictions are very serviceable, particularly when per- 



AMENORRHEA. 789 

formed with a horse-hair glove. Rubefacients, and even more severe 
contra-irritation, by means of mustard plaster, blisters and antimonial 
ointment are also found useful for relieving internal pains. A local 
stimulant is much employed in England, composed of one or two 
drachms of the aq. ammonias pur. to twelve or sixteen ounces of 
warm milk or thin starch ; ttiree or four ounces of which are injected 
into the vagina four or five times daily. 

The mechanical obstructions in the passages may be divided into 
two classes: viz., those occasioned by cohesion of the sides of the 
vagina or labia, and an imperforated hymen ; and those caused by 
an imperfect or imperforated state of the os uteri itself. All these 
cases are comparatively rare, but few men can have been in exten- 
sive practice for twenty years without meeting with several, and 
therefore they require some notice in this place. In the first set of 
cases, in addition to the constitutional symptoms and local pain already 
mentioned, there are great fulness, distension and a sense of weight 
in the passages, accompanied sometimes with severe pain, and a 
feeling of bursting; straining at stool and micturition; together with 
enlargement of the abdomen, which excite suspicion of pregnancy. 
The nature of the case can only be determined by examination, and 
can be relieved only by the knife. 

In the second set of cases, there is greater difficulty in detecting 
the state of parts, from the natural impediment to an examination 
which exists at the orifice of the vagina; but I may mention, at 
least as a curious coincidence, that in the only two cases of imperfo- 
rated os uteri which have fallen within my observation, there was 
no hymen, and the passages easily admitted the introduction of two 
fingers. In a third case of very imperfectly formed os uteri there 
was a hymen, but it offered no obstacle to the necessary examina- 
tion. One of the former individuals would not submit to the os uteri 
being punctured, became perfectly exsanguined and chlorotic, affected 
with difficulty of breathing, cough and expectoration, and died since 
the publication of the last edition. The other case I shall now 
relate: A young- woman, aged £2, came from the country to con- 
sult Dr. J. A. Robertson, who M-nt her to me in the beginning of the 
winter i v -''>. The following particulars werecollected from herself 
run! a I'm tie friend who accompanied her. The menstrual discharge 

had not yet appeared; she had always been healthy till she reached 

the age of sixteen, from which period her health began to Buffer, and 
since which Bhe had regularly complained every month of pains in 
the back and loins, together with a sense of weight and hearing 
down in the passages, For some time her sufferings were slight, 
and she- was still able to perform her duties as a servant, but for the 
• wo years she had become comparatively weakly and emaciated-, 

not knowing whit it was tO 60Joy a day's rase ; and sh" Stated that 
she would readily submit to any thing which might cure her. The 

girl appeared to be above the middle stature, the mammas were un- 
developed, she was o!' an awkward shape, and, indeed, her appe tr- 
ailer, colour of skin and sound of voice were rather masculine. 
Her abdomen was not tumid, but it was stated to be occasionally 
swollen, particularly after meals. She seemed to be of a nervous 

66« 



790 AMENORRHEA. 

temperament, and was exceedingly shy and timid. Upon examina- 
tion, the fingers passed readily into the vagina, and the litems was 
felt much lower than usual, but I could discover no orifice. Dr. Ro- 
bertson had previously detected the same fact, but had not then com- 
municated the circumstance to me, thinking he might be mistaken. 
The examinations were repeated many times, and after feeling the 
spot where the orifice ought to have been, which was distinguished 
by a small dimple, I attempted to introduce one of the smallest sil- 
ver probes that could be made, but was unsuccessful in every at- 
tempt. It then occurred to me, that the malformation might be 
owing to an extension of the mucous membrane over the orifice, in 
which condition we sometimes see the urethra of a new-born male 
child. I determined upon giving her the chance of a cure, particularly 
as the means to be used would not certainly produce severe pain. 
Accordingly, the sharp and triangular extremity of a silver probe 
was introduced, directed by the finger, and carried to the part above 
described, and a perforation made by employing a rotatory motion; 
the instrument was then withdrawn and the round point introduced, 
which then readily passed up to the fundus of the uterus. For seve- 
ral days she complained of slight pain, attended with some discharge 
of mucus, a little tinged here and there with bloody specks; and 
nothing further was done till the irritation had subsided. In about 
eight days the further dilatation was attempted and persevered in 
daily, the size of the instrument being increased, till by the twelfth 
or thirteenth day I was able to introduce No. 6 male bougie to the 
fundus of the uterus. On the following day there was the appear- 
ance of so much irritation, both local and constitutional, that no fur- 
ther attempt was made. In two days afterwards she menstruated, 
and has been regular ever since, and suffers neither pain nor inconve- 
nience. Her health and strength soon recruited, and, in a short time 
her appearance became quite feminine. I saw her accidentally a 
few months before this article was corrected for the fourth edition in 
1835, and she was then in the enjoyment of good health. 

In the case of amenorrhoea from imperfectly formed os uteri, the 
patient had at various times been afflicted with violent symptoms; 
pain in the abdomen, sometimes of a distressing nature, and obstinate 
affections of the stomach and bowels; together with occasional re- 
tention of urine, and anomalous hysterical complaints. At every 
menstrual period she passed a little mucus, which was now and then 
slightly tinged, but had never the natural appearance, and it was 
always attended with great pain. After attaining the age of twenty- 
three, when her health was greatly impaired, and after she had tried 
all known remedies in vain, she most reluctantly, and after great 
delay, submitted to examination ; and the os uteri was found so 
small as to be scarcely perceptible. She menstruated satisfactorily 
after several bougies had been passed through the os uteri, but I 
never succeeded in penetrating completely into the cavity of the 
uterus, either from an obstruction in the cervix, or from what ap- 
pears to me to be more probable, a curvature of the canal. Never- 
theless, after dilating the passage as far as could be reached, (No. 7 
bougie,) she menstruated naturally, freely and without pain, and her 



AMENORRHEA. 79L 

health became wonderfully improved. It is but fair to mention, 
however, that this case was also complicated with extensive constric- 
tion of the rectum, which, I fear, is not yet completely removed. 
Since the publication of the former editions several cases have oc- 
curred, the majority of which have terminated successfully: but in 
candour I must state, that in one case a complete failure took place. 

Retention of the menses, arising from or accompanied by general 
debility, must be treated by means adequate to restore the health 
and strength of the individual, in addition to the other remedies above 
mentioned. 

Suppression of the menses. — The second variety of amenorrhea 
is, suppression of the menstrual discharge, which may occur in two 
circumstances; either it may not return at the next expected period, 
or it may be suddenly checked during its flow; and this last has 
been termed " checked menstruation." Women affected in this 
manner are said to be obstructed. 

The first circumstance is one of the natural effects of pregnancy, 
and is sometimes produced by disease — for example, by general bad 
health; weakness caused by great loss of blood; long-continued 
fatigue; exposure to cold at the time the discharge was expected; 
improper food ; excessive mucous discharges, as in leucorrhcea; fre- 
quent abortion, which injures the healthy functions of the uterus, and 
also by various diseases of the uterus. 

The second circumstance may be produced, also, by exposure to 
cold, but is often the immediate effect of violent mental passions. 
Grief has often this effect : and I have known it caused by excessive 
joy. Constipation must likewise be regarded as a cause, particularly 
of the first variety. 

When the menses are suppressed, haemorrhage frequently takes 
place from the lungs, stomach and nose ; the abdomen becomes 
lomefied and painful; the mamma?, are sometimes tense and painful ; 
the tongue is generally foul ; the appetite bad; occasionally feverish 
■ y ptoins take place; and BOmetimee death follows in the train of 
consequences. 

Treatment tf suppression of the 7/ienscs. — In checked menstrua- 
tion 1 have seen the discharge brought back in twenty-four hours by 
proper treatment II there be much vascular excitement, the lancet 
may he necessary in full, plethoric individuals; and the blood may 
be liken from the lower extremity, if a vein can be found conve- 
niently situated ; but, upon the whole, leeches are preferable, applied 
to some part of the pelvic region, or to the os uteri. If the patient 
be not troubled with piles, two aloetic pills may be given every third 
or fourth hour, till the proper effect is produced, except in cases of 
excessive COOBtipatioB, when milder remedies are to be used, as- 
sisted by large injections of tepid water. A case so complicated 
may require reneeection. The warmammoniacal injection may, at 
a ■nbeeqoenl period, be thrown into the vagina and the feet bathed 
in very warm water; but the hip-bath, impregnated with mustard, 
will be found most beii'luial. 

When obstructions take place in debilitated constitutions, purging 
must not be carried too far; indeed, it may be mentioned as a gene- 



792 DYSMENORRHEA. 

ral rule that strong physic should not be given in such circumstances: 
but the bowels ought to be kept gently open by suitable medicines, 
and particularly by mild injections. The patient should be allowed 
a nutritive diet, easy of digestion ; and a sufficient quantity of wine 
or brandy, if the former do not agree, will be found to be the best 
tonic; but the diet, the exhibition of stimulants and tonics, should 
be regulated by the circumstances attending each particular case. If 
the stools show that the food is passed undigested, or if the tongue 
be furred, or be red and dry, animal food of any kind must be given 
with caution, and I think prohibited altogether when the tongue is 
in the condition above described ; but there can be no objections to 
the use of wine; indeed it will, in general, be beneficial, unless it 
excite fever. 

In many cases of derangement of health in females, a shower-bath, 
taken immediately before dinner, will be found serviceable, and may 
be used with warm or cold water, according to circumstances; but 
generally, the more a patient is debilitated, the warmer should be 
the water: the body should be afterwards well dried, and fresh gar- 
ments put on. Exercise, and other remedies already so fully noticed, 
must be had recourse to. It may be further added, however, that 
preparations of iron are in great repute, and are well known to wo- 
men under the name of "steel pills," " steel drops," &c; but I believe 
they have no specific effects; should other remedies fail, however, it 
may be as well to try them. [The preparations of iodine, particu- 
larly the hydriodate of iron,* have proved singularly beneficial in 
this form of amenorrhoea.] 

It becomes a question how far the introduction of the bougie 
into the uterus may be applicable in obstinate cases of this kind, 
when other remedies have failed, and the general health has be- 
come affected. I have tried it in three bad cases: in two of these 
the menstrual discharge appeared soon after, in the third it com- 
pletely failed ; but the first two cases are scarcely to be regarded 
as satisfactory, because other remedies were employed at the same 
time. 

DYSMENORRHEA, OR PAINFUL AND DIFFICULT MENSTRUATION. 

Although, in dysmenorrhoea, the discharge is generally scanty, 
yet it is sometimes in natural quantity; in some instances the dis- 
charge contains fibrous shreds, while, in others, a small organized 
mass, the shape of the cavity of the uterus, which, in common lan- 
guage, is called a "false conception," or a "mole," is thrown off. 

A few days before the discharge is expected to appear, women 
affected with dysmenorrhoea begin to complain of pain, more or less 
severe and constant, in the back and loins, as well as in the pelvis; 
at last a scanty discharge appears, attended with increasing pain and 
suffering. In investigating into the precise nature of these pains, 
they have been described to me in various ways, and as existing in 
various degrees, from a sense of weakness, weariness, weight and 

[* See Appendix, Alteratives.] 



DYSMENORRHEA. 79S 

tightness, to violent cramp, spasm, colic and bearing down, which 
last is sometimes so violent as to resemble the expulsive pai; of 
labour, particularly when shreds of membrane are passed, and still 
more so when an organized mass is expelled. The abdomen becomes 
swollen, sometimes tense; flatus may be heard moving from one con- 
volution to another; the appetite is impaired; the bowels are consti- 
pated ; the stomach is often irritable, sometimes affected with violent 
vomiting; the tongue is foul, and there are often febrile symptoms; 
the urine is sometimes suppressed, at others retention takes place. 
Some women suffer pain only during the first day, while others do 
so during the whole period. 

Dysmenorrhea sometimes takes place from the very commence- 
ment of menstrual life; or it is dated from the period of marriage; or 
after the birth of a child, generally speaking, the first child; lastly, 
it may take place at any period of life, and, in such cases, it is gene- 
rally attributed to cold. The disease is of very common occurrence ; 
much of the distress and bad health of females is owing to it, and 
many fall victims to consumption in consequence of diseased action 
being excited in the system by the periodical sufferings. These peri- 
odical sufferings, however slight at first, afterwards become more 
severe and of longer duration, so that, at length, some women are 
beginning only to recover from the effects of one period when the 
approach of the next is close at hand. At last, from the combined 
inlhience of the actual suffering during the periods, and the anxiety 
of mind during the intervals, the patient's health and strength are 
entirely destroyed. This would happen much more frequently and 
speedily than it actually does, only that females do not suffer with 
equal severity at every period; and the remark has often occurred 
to me, that alter a very severe time, women escape once, and some- 
times twice, with comparatively little uneasiness; but when the third 
period arrives, it is generally attended by very violent pain: this is 
more particularly the case when shreds of membrane and organized 
substances are discharged. 

It has been generally remarked, that few women affected with 
dy.Miieiioniin-a bear children, and u is described by all authors as a 
i.ikvs. .Mr. Hums makes the following statements 
When treating of the causes Of" sterility: — "The menses are either ob- 
structed or sparing, or they are profuse or too frequent}" and again: 
«Il is extremely rare be a sfotnan to conceive who does not men- 
struate regularly: and, on the contrary, correct menstruation generally 
indicates s capability of impregnation on the part of the woman." 
Dr. Mason Good, when speaking of the sufferings of women affected 
with dysmenorrhoe t, makes the following statement : "The frequent 
return of srhieh embitters the life of the patient, and effectually pro- 
hibits all hope of a family." Dr. Denman supposed thai no woman 
in such cirenmstances can conceive. There can be no doubt, how- 
ever, thai Dr. Denman was not quite correct in making tins state- 
ment; but there can belittle question of the fact, as already mentioned, 
thai conception ii i ire. 

Dysmenorrhesa has been ob ser ved in females under the most op- 
posite conditions of the system, temperaments and habits. Soino 



794 DYSMENORRHCEA. 

are affected with hysterical symptoms, others not ; but in all circum- 
stances, the disease is represented by authors as most intractable; and, 
indeed, it is stated by one and all of them, that the treatment consists 
in palliating symptoms during the period of suffering, and that "time, 
in general, removes the disease better than medicine, which is only 
to be advised for the relief of pain, weakness or any other symptom 
which may attend or succeed to this state. Dr. Mason Good, in 
noticing the intractable nature of the affection says, "The disease, 
moreover, is peculiarly obstinate, and, in some instances, has defied 
the best exertions of medical science, and has only yielded to time 
and the natural cessation of the discharge." 

Pathological remarks respecting dysmenorrhcea. — Dysmenor- 
rhea has been attributed to inflammatory action in the uterus, par- 
ticularly when membranous and organized substances are discharged. 
These were proved by Dr. Hunter and Dr. Baillie to resemble the 
membrana decidua, formed by the lining membrane of the uterus 
immediately after conception. The disease has also been attributed 
to spasm; and loose and obscure hints are given, in various works, 
of its dependence on organic affections of the uterine system. Thus 
Mr. Burns has observed, "If no organic affection can be discovered, 
and the whole appears to arise from spasm, we have only to trust to 
opium in the mean time, with such treatment in the intervals as the 
state of the system may point out." There are others who suppose 
that the disease is owing to a want of nervous energy in the uterine 
system — to constipation — or exposure to cold and damp. 

It always appeared to me, that there might be some mechanical 
cause for dysmenorrhcea, but it was not till the year 1S23 that I first 
entertained a belief it might be owing to the small size of the os 
uteri. In that year a medical friend presented me with a prepara- 
tion of the uterus and its appendages, in which the os uteri was so 
small as scarcely to admit a hog's bristle. Since that period, I have 
had many opportunities of investigating this interesting subject, and 
have now obtained many preparations taken from the bodies of indi- 
viduals who died of different diseases, particularly of phthisis, and 
whose histories prove, that they had laboured under dysmenorrhcea 
from the very beginning of their menstrual lives. In these prepara- 
tions of the uterus, the orifices, instead of being shaped like the mouth 
of the tench fish, are either circular, or nearly so, and some of them 
are so small as only to allow a bristle to pass; others are a little 
larger, admitting a small silver probe. 

I am far from alleging, however, that dysmenorrhosa is always 
produced by a small os uteri ; on the contrary, I believe it may occa- 
sionally depend on inflammation of the lining membrane of the ute- 
rus, as well as on inflammation in the substance of the cervix uteri, 
and on the encroachment of tumours diminishing the calibre of the 
passage through the cervix. But I maintain, that the condition of 
the os uteri above described accounts satisfactorily for many cases 
of dysmenorrhea — so far as my investigations have extended, I am 
inclined to say it will account for the majority ; although in candour 
I must mention, that one preparation in my possession appears to in- 
validate the evidence afforded by the others. In it, the mouth of the 



DYSMENORRHEA. 795 

uterus is very small, and yet the woman to whom it belonged is 
stated to be the mother of several children ; she died in a public 
establishment, but the history of her menstrual life is unknown. 

By this condition of the os uteri, not only are all the phenomena 
which take place in dysmenorrhoea most satisfactorily accounted for, 
but also the intractable nature of the disease, and the unsatisfactory 
result of every mode of treatment hitherto recommended. The 
menstrual discharge, after it is secreted in the u ret us, cannot readily 
escape in consequence of the small size of its orifice ; distension of 
the organ is the consequence, which, by exciting the contraction of 
its fibres, produces uneasiness and pain in the pelvic region. When 
the os uteri is very small, and the secretion viscid or mixed with 
coagulated blood, shreds of membrane or organized masses, then the 
distension becomes more considerable, stronger contractions are ex- 
cited, producing violent pain. Sometimes the action of the abdo- 
minal muscles is called into play, and bearing-down or expulsive 
pains are produced, resembling, in every particular, the pains of 
labour, and continue till the expulsion takes place. Mr. Burns, in 
speaking of the disease, states that it " sometimes produces, besides 
uterine pain, spasmodic affection of the bowels, or violent bearing- 
down efforts of the abdominal muscles, as if it were intended to 
expel the womb itself." 

During these periodical attacks, inflammation of the lining mem- 
brane of the uterus, if it do not already exist, is sometimes excited, 
and in the end the sufferings occasion an entire break-up of the con- 
stitution. That dysmenorrhoea should be so intractable, and the 
action of remedies so very unsatisfactory as to render the disease an 
opprobrium to medical science, are not to be wondered at, if my 
views be hereafter found to be correct. Before I had any opportu- 
nity of putting these opinions to the test of experiment, they also 
appeared to me to be corroborated in a very striking manner by two 
circumstances: — 1. By the action of the ergot of rye, which in- 
creases the force of the uterine contractions, quickly expelling the 
contents of that organ, thus, in some cases, shortening the patient's 
sufferings materially. 2. By the admitted fact, which has been al- 
ready mentioned, that women affected in this manner rarely, if ever, 
conceive. The small size of the os uteri renders impregnation 
almost an impossibility, by offering a mechanical obstruction to the 
passage of the semen into the cavity of the uterus, which it must 
reach, as proved by the accurate experiments of that ingenious and 
distinguished physiologist, Dr. Blundell, of London, as well as by 
other facts which it is unnecessary to mention in this place. 

These views appear to me to be further supported by several pre- 
parations in my museum. In one of these, the cavity of the uterus 
is divided into two compartments, by a strong transverse adhesion. 
In a second, occlusion 01 the passage exists at the upper part of the 
cervix, with appearances of having been produced by tin; irritation 
of a polypous tumour j and in a third preparation, the os uteri be- 
came sealed up by inflammatory action. On dissection, the uterus, 

in this last case, was found enlarged, and contained about two ounces 
of puriform matter. 



796 DYSMENORRHEA. 

Treatment of dysmenorrhea. — After the facts and observations 
above mentioned were collected, my mind became occupied with 
devising the best means likely to cure the disease. Mechanical 
dilatation appeared to be the only remedy. I hesitated for some 
years to carry it into execution, or, indeed, to propose it, beyond men- 
tioning it in my lectures, till the case of the young woman affected 
with arnenorrhoea, recently noticed, presented itself in the year 1S26. 
Since that period I have treated twenty cases of dysmenorrhoea, by 
dilating the os uteri, and have permanently cured eighteen of the 
patients ; among these the two cases of arnenorrhoea formerly men- 
tioned are not included. 

Of the eighteen successful cases, eight were either young unmaried 
women, or living in a state of widowhood ; ten were married, and 
living with their husbands. Of these ten, seven subsequently fell 
with child. This is the statement made in 1832. Since that period 
I have tried the practice, after every other means had failed, in seven 
cases : in one of the seven only has it failed; the others have been 
completely and permanently cured. Of the six successful cases, 
four have since had a child each. Thus, in twenty-seven women, 
twenty-four cures have taken place, and of these, eleven have since 
had children. This plain statement of facts, and a visit to my mu- 
suem, should stop the sneers of an illiberal brotherhood. 

The instruments employed to produce the dilatation are the com- 
mon metallic bougies, of different sizes, from that of the ordinary 
small silver probe to No. 14. The operation is performed, (the pa- 
tient lying in the position in which women are usually delivered in 
this country,) by introducing the index-finger of the left hand, till it 
reaches the os uteri, for the purpose of directing the instrument to 
the part, which is then to be gently insinuated by a rotatory motion, 
till it arrives at the fundus of the uterus. Much force ought not to be 
employed, and little or no pain is produced by the operation. The un- 
pleasant consequence which sometimes takes place in treating stric- 
ture of the urethra by similar means, viz., shivering, followed by fever, 
occurred in two instances; the fever, however, was slight, and soon 
terminated by copious perspiration ; and in these, some days were 
allowed to elapse before the instrument was again used. In two of 
the cases, the os uteri was sufficiently large and well shaped ; but 
the passage became so narrow in the course of the cervix of the 
uterus, that it required long-continued efforts before the smallest in- 
strument could be introduced ; but by perseverance the obstructions 
were at last removed,and the patients cured. In one of these last two, 
menstruation was performed without pain till after marriage, when 
dysmenorrhoea occurred. The other was a young unmarried woman 
who menstruated with ease for several years, but after long exposure 
to cold and moisture, the menstrual discharge became, for a time, 
suppressed, and ever after was performed with pain. The late Dr. 
Kellie, of Leith, was also consulted about this case, and had I not 
been encouraged by his advice, I should not have attempted the 
operation, as on the posterior lip of the os uteri several small eleva- 
tions like incipient tubercles were felt. This woman called upon me 
eighteen months afterwards in good health, and stated that she had 



DYSMENORRHEA. 797 

not felt any uneasiness or experienced any bad symptoms since the 
dilatation was effected. 

A lady, the subject of one of the twenty-seven cases, was also per- 
fectly healthy, and menstruated easily till the period of marriage ; 
but her health became impaired soon after, in consequence of her 
monthly sufferings. On making an examination, an enlargement 
was discovered, about half the size of a chestnut, on the posterior 
surface of the cervix of the uterus. I undertook the operation in 
consequence of the urgent entreaties of her friends, who happened 
accidentally to know of the happy results which had attended it in 
other cases, but little hope was offered of being able to do any good; 
notwithstanding which, a striking improvement in her health soon 
took place; and this, in the end, proved to be one of the most success- 
ful cases, for menstruation became easy, the tumour rapidly declined, 
and upon making an examination in about twelve months after- 
wards, it could scarcely be felt. 

Nunc of the women operated upon had suffered for a shorter pe- 
riod than two years; some for three or four; and others for ten. Of 
four of those who subsequently fell with child, one had been married 
between seven and eight years, and was reduced to a shadow from 
constant ailments; but after the operation, she recovered her health, 
strength and flesh, and became pregnant at about the termination 
of nine months from the date at which the bougie was used for the 
last time. Another had been married three years, and had suffered 
considerably in constitution, with severe nervous symptoms every 
month, till at last she became entirely obstructed; and the abdomen 
being enlarged, I was consulted upon the supposition that she was 
five months gone with child. From some circumstances which it is 
unnecessary to mention, I entertained a suspicion that she had de- 
ceived herself; and upon making an examination, when she supposed 
herself to be in the seventh month, ascertained beyond all doubt that 
this was not the case. In the process of time, the operation was 
performed, and the passage completely dilated — some months after- 
wards impregnation took place, and I have since delivered her of 
three children at separate births. 

A third case is that of a lady who had been married two years, 
and who had had painful menstruation from the first appearance of 
the discharge; she was in a miserable state of health, had taken a 
great deal of medicine, but only with temporary relief. Impregna- 
tion took place after the third menstrual period subsequent to the 
dilatation. 

The subject of the fourth case had also been affected from the first 
of her menstrual life, and laboured under the impression that she 
was therefore never to have a child. After dilating the passage with 
.No. 8 bougie, menstruation took- place with so much ease, thai she 
supposed le- 1 elf quite cured, and would not again submit i<> the ope- 
ration. Several months afterwards, however, she fell a return of the 
pain, the operation was again had recourse to, and the dilatation car- 
ried as far as it could he effected with No. lo, which was ace.oin- 
plished two days before- her expected period. Menstruation took 
in 



798 IMMODERATE FLOW OF THE MENSES. 

place freely, and without the slightest uneasiness; she subsequently 
fell with child, and was delivered of a boy. 

In cases of dysmenorrhoea, when this operation may not be expe- 
dient, the ordinary plan of treatment must be had recourse to — viz.: 
palliating symptoms by means of the hip-bath, attention to the diet, 
the due regulation of the bowels and the occasional administration 
of opiates. 

If the existence of inflammatory action be suspected in the lining 
membrane of the uterus, or should there be much fever, it is neces- 
sary to apply leeches internally, or use cupping-glasses to the lower 
part of the back. Since the year 1832, 1 have been induced fre- 
quently to apply leeches internally in cases of dysmenorrhoea, and I 
have thought always with advantage. 



IMMODERATE FLOW OF THE MENSES. 

Women sometimes menstruate more copiously than they usually 
do, so much so, that it appears more like a flooding than menstrual 
discharge; but the difference is easily known by the peculiar smell 
and appearance, and by its not coagulating like blood. This disease 
is, in general, confounded with haemorrhage from the uterus, and the 
general term menorrhagia has been applied to both, either when 
separate or conjoined. I agree with Mr. Burns, however, in restrict- 
ing the term menorrhagia to the discharge of pure blood from the 
uterus ; but in order to be clear and precise in our language with 
respect to the combined case, we may then say that excessive men- 
struation is complicated with uterine haemorrhage. 

Many women menstruate more frequently and more copiously 
than others, and yet they cannot be said to be diseased, because it is 
natural to them. Therefore it is only to be considered as a disease 
in the following circumstances— viz.: when it is not habitual, and 
when it produces weakness or other unpleasant symptoms. Profuse 
menstrual discharge takes place in every variety of constitution and 
habit, but is observed more frequently in people of a debilitated, 
weakly and relaxed frame of body, and in those whose occupations 
lead them to constant exposure to heat. 

Treatment of profuse menstruation. — Medical men are seldom 
consulted in this affection, except in the worst cases. Should the 
strength be much reduced, every means must be taken to restore it 
by proper nourishment, a due regulation of the bowels, the mildest 
laxatives, and the administration of wine if necessary. During the 
attack, the necessity of rest in the horizontal posture should be strong- 
ly inculcated; and in the intervals, great attention must be paid to 
regulate the exercise, so that it may be always short of producing 
fatigue. The shower-bath, bathing the lower part of the body twice 
a day in cold water, and even open sea-bathing, may be recommended, 
under the restrictions which have been so fully insisted upon in the 
former part of this chapter. Perhaps the acetate of lead may be 
found of as much service in diminishing this as it has been in other 



MENORRHAGIA. 799 

discharges. Should there be any uterine pain or irritation, recourse 
must be had to opiates. 



MENORRHAGIA. 

I agree with Mr. Bums in the propriety of restricting this term to 
actual haemorrhage from the uterine vessels. This discharge occurs 
in every state of constitution, affecting full plethoric individuals, of 
active habits, equally with those of a weak and relaxed frame. In 
the former, it may continue for a considerable period without making 
any inroad upon the general health; but in the latter, the system soon 
feels the drain ; and, in either case, if the discharge continue long, the 
constitution becomes irreparably destroyed. Much depends upon 
the quantity of blood lost, and upon the length of interval between 
the attacks. Besides the weakness produced by the loss of blood, 
the debility is also increased by leucorrhoeal discharge, which, in 
general, supervenes, together with disordered functions of the sto- 
mach and bowels; the appetite soon becomes impaired, and even 
destroyed, and the bowels irregular, with frequent attacks of diar- 
rhoea, which depress the vital powers nearly as much as the original 
disease. 

Menorrhagia is generally accompanied by pains in the back and 
loins, frequently by a shooting pain through the pelvis, and some- 
times by fever. Anomalous hysterical symptoms frequently ensue, 
together with occasional distressing paroxysms of palpitation. It is 
worthy of remark, that sooner or later, symptoms denoting a violent 
affection of the brain take place so similar to those which are known 
to be produced by a determination of blood towards the head, and 
inflammatorv action in the brain itself, that it is to be feared cases 
of this description have too often been treated by depletion. The 
symptoms are vertigo and headache, both of which are increased by 
the patient raising her head, by noise, or by any one walking through 
the room. Every time the patient makes any attempt to raise the 
head, syncope is threatened; there is a constant singing in the cars; 
the 1 nerally weak and compressible, quick, and in many 

cases exceedingly irritable, so much so as Bdmetimea to appear pretty 

strong ami wiry for a few fniUUtes, which, I have no doubt, often 

imposes a belief that inflammatory action is going on, when really 
(he brain is suffering from tin- want of a proper quantity of blood, 
as well as from deficiency of impulse. 

Cause* of monorrhagia. — Thia disease may depend upon general 
or local plethora; upon general debility; upon excessive leucorrhoeal 
discharge and frequent abortion, which probably produce uterine 
debility ; and upon th.: inflammatory action, perhaps of a subacute 
nature, of the I mm'/ membrane of the uterus, together with that of its 

follicular Structure, as well as ulceration at the 08 uteri. Menor- 
rhagia has also been attributed to constipation and excessi we venereal 
indulgence; but these can only be regarded as occasional exciting 
causes m persons strongly predisposed to the disease. Prolapsui 
and pdlypUS uteri, together With scirrhous and cancerous affeCtiOBt 



800 MENORRHAGIA. 

and diseases of the ovaries, also occasionally give rise to menor- 
rhagia. 

Treatment of menorrhagia. — From the facts above stated re- 
specting the various causes of the disease, the necessity of an exami- 
nation per vaginam will be evident ; but in the case of an unmarried 
woman, it is only to be had recourse to when the disease resists the 
effects of ordinary treatment. The management of a patient during 
an attack of haemorrhage is simple, and will, in general, be success- 
ful in restraining the discharge, if it does not depend upon extensive 
organic disease ; but even then it will be often serviceable. In every 
case, the patient must be kept quiet in bed, without being overloaded 
with bed-clothes; but at the same time a comfortable degree of heat 
is to be preserved, otherwise bad consequences will be produced. 
The discharge has been rather increased by the surface of the body 
being kept so cold as to occasion shivering, or even chilliness. 

In full, plethoric constitutions, if there be no organic disease, and if 
the pulse be full and strong, venesection will sometimes check the 
discharge instantly, and is employed upon the same principles as in 
epistaxis, haemoptysis, &c. — viz.: altering the determination of blood 
and reducing the impetus of the circulation. The beneficial effects 
of leeching have surprised me much in several cases of menorrhagia, 
even when the discharge was complicated with extensive disorgani- 
zation. I was first induced to apply leeches, in order to relieve 
uterine pain and irritation, exciting a determination of blood to the 
parts, and keeping up the haemorrhage, and have since had recourse 
to this practice with much success in cases where venesection was 
altogether inadmissible. On several occasions, the haemorrhage 
ceased almost instantaneously after the leeches had fastened, and 
before they could have abstracted a dessertspoonful of blood. In 
plethoric constitutions, the diet should be scanty, and not very nou- 
rishing, and the bowels should be kept open by means of gentle, 
unirritating laxatives. 

When menorrhagia occurs in weak, debilitated habits, or when 
the discharge is continued so long as to produce debility, the patient's 
strength must be supported by small quantities of nourishment given 
at short intervals, together with wine or brandy, notwithstanding the 
supervention of the giddiness, and other symptoms which generally 
indicate a severe cerebral disease. Rest in the horizontal posture, 
with the head and shoulders low, and the most perfect state of quiet- 
ness, are to be insisted on : and as the loss of every drop of blood is 
felt in the reduced state of the system, means must be instantly taken 
to put a stop to further discharge. This is best effected by the ex- 
hibition of the acetate of lead in the form of pills, each containing 
from two to five grains, combined with a third or fourth of a grain 
of opium, of which one or two may be given every second, fourth 
or sixth, hour, as the urgency of the case may demand. As to its 
action I know nothing, and practical men of the present day care 
little about mere theories; but I have alluded to the subject, in order 
to speak of one theoretical objection that has been made to the prac- 
tice. It is asked, if you were to cut your finger, would you think of 
trying to restrain the haemorrhage by taking acetate of lead or any 



MENORRHAGIA. 801 

other astringent ? The answer is— certainly not, as there is a more 
easy and speedy method of doing so; but as we cannot apply a 
tight haudage round the uterus, or secure its vessels by ligature, we 
are obliged to have recourse to the other means, which has been 
suggested by analogy, and the success of which has been proved in 
actual practice. 1 subjoin the following short history of a case of 
monorrhagia, the most threatening and the most hopeless that ever 
fell within my observation, which was successfully treated bv the 
acetate of lead. A lady, aged 47, the mother of a large family, of 
very delicate constitution, who had always been liable to profuse 
and frequent menstruation after fatigue, any unusual bodily exertion, 
the application of cold, &c, was seized, during the autumn of 1829, 
with profuse menorrhagia, which returned from time to time for six 
or seven months, each attack leaving her more and more debilitated 
and depressed, till, at length, the discharge never left her, and no 
remedy had any influence in controlling it. At last she was told 
that no medicine taken internally could have any effect, and that her 
only chance depended upon keeping quiet, and throwing into the 
passages a solution of the sulphate of alumina, which was tried, but 
without effect; and, indeed, she felt that she could not bear the 
fatigue attending the operation. At this juncture, her relations sent 
for me, when she was in the following condition. The discharge 
still gushed from her, whenever she was moved for any necessary 
purpose; she was more exsanguined than any person I had ever 
before seen; the surface of her body was the exact colour of death; 
and she had the hippocratic countenance. Her pulse was weak, 
small and compressible, and beat about 100. — She was perfectly 
sensible, but was affected with giddiness, headache, singing in the 
ears,, a feeling of sinking, and she could scarcely speak without 
swooning. She had been for some time almost a stranger to sleep, 
and when she did slumber for a few minutes, she invariably awoke 
in terror and great agitation. A bowel-complaint had lately super- 
vened, which added to her distress and increased her weakness, and 
for some days there were great irritability of stomach and vomiting, 
particularly when attacked with increased giddiness. 

Tli'- treatment was immediately changed ; warmth was applied 
and other means were taken to restore and support the heal of the 
body; the bolster and pillows were withdrawn so as to lower the 
head, and 5 grains of the acetate of lead, with half a grain of opium, 
were ordered to be exhibited every third hour till she had taken the 
fourth dose. One person only was allowed to he in the room, and 
was desired to give her small quantities of brandy in some nourish- 
ing Vehicle at Short intervals if awake, but On no account was she to 

be distiii bed, at least for several hums. My first visit was made in 
the evening, when the pills were ordered ; .ind calling again at a late 

hour, she was quiet, composed and full Of hope, as there hid been 
BCaKery any discharge for two hours. She had just taken a second 
dose. 

V \t morning I found that my patient had enjoyed several hours 
of refreshing sleep -that the restlessness had considerably subsided 

— and that the discharge was quite suppressed. The other symptoms 

87* ' 



802 MENORRHAGIA. 

were much the same, and I was told that early in the morning, she 
had had a violent attack of vomiting with syncope, which threatened 
the extinction of life, but which went off after taking some additional 
nourishment, as soon as her stomach could be brought to bear it, and 
by the exhibition of powerful stimulants. She expressed herself in 
strong terms respecting the happy change effected in such a short 
space of time upon both body and mind, and her confidence of ulti- 
mate recovery. The effort to speak nearly produced syncope, and 
occasioned considerable irritation of stomach, and that condition 
which in Scotland is termed " dry bocking."* The nourishment and 
stimulants were ordered to be continued at short intervals, and pills 
with two grains of the acetate of lead and one-third of a grain of 
opium were prescribed, with intervals of six hours instead of three. 

At the evening visit, she was much in the same state, only that she 
laboured under a little agitation, in consequence of a return of the 
discharge on two occasions upon making some exertion; I found, 
however, that it was very small in quantity, and ordered the larger 
doses of the acetate of lead and opium to be given twice during the 
night, with an interval of four hours, and afterwards to recur to the 
use of the two-grain pills. She was persuaded to allow herself to 
be turned upon her right side, in which position she was supported 
and propped up by means of pillows, and a very small pillow was 
now placed under the head. From this change of posture she ex- 
perienced great comfort, and on my visit next day I was told that she 
had slept soundly the whole night, waking only now and then, when 
she got nourishment — that she had a return of syncope and vomiting 
early in the morning, but neither were so violent as formerly. She 
could now make use of slight exertion, and speak without the same 
bad consequences as those above described ; the singing in her ears 
still existed, but was not so noisy and troublesome: still, however, 
she could not raise her head from the pillow without increasing it, 
producing giddiness and a tendency to faint. It was now time to 
obtain passage from her bowels, although there was some risk of 
producing a return of the flooding. A teaspoonful of castor oil was 
exhibited, by which the bowels were moved, but, as was apprehended, 
there was some haemorrhage at the time, though it did not alarm the 
patient much, as she was prepared to expect it. 

In the evening she felt a little better, and had passed the day 
without any additional haemorrhage, having taken only one of the 
smaller pills. She was now able to turn herself upon her side, and 
back again at pleasure, but still required the support of pillows. On 
taking my leave, I gave her one of the larger doses, and desired that 
she was to take nothing during the night, except nourishment, with 
small quantities of brandy; this was found to agree with her better 
than wine, which became acid in her stomach. 

On the following morning, I found that she had slept well during 
the night; she looked and felt better; her pulse, for the first time, 
felt stronger and slower; but she complained of pretty constant nau- 

* Which term means continued retching without discharging any thing from the 
stomach; the pain and sinking effect of which are known to every one who has suf- 
fered long from sea-sickness when the stomach was empty. 



MENORRHAGIA. 803 

sea and oppression at the praecordia. This last I thought might be 
attributed to the action of the lead, and it was therefore discontinued 
in the larger quantities; indeed, only two of the smaller pills were 
subsequently given. By good nursing and attention to the proper 
regulation of the diet and stimulants, this lady made a perfect re- 
covery, notwithstanding one or two subsequent attacks of bowel- 
complaint, which she experienced during her convalescence, and 
which threw her back: considerably. Five years have since elapsed. 
She has menstruated regularly in proper quantity, there has been 
no threatening of a return of the haemorrhage, and her health is 
good. 

Opium is to be used in doses of one, two or three grains, accord- 
ing to circumstances, in cases of menorrhagia, where the discharge 
is kept up by general or local irritation. Its beneficial effects will 
be satisfactorily seen by the perusal of the following case: — A lady, 
about the period of the « change of life," was seized with menor- 
rhagia. She had the best advice that could be obtained, and had 
taken every remedy which had ever been recommended for the sup- 
pression of uterine haemorrhage, but without effect. The passages 
were stuffed with soft linen in vain, the discharge returned as soon 
as it was withdrawn; she became exsanguined, and seeing no hope 
of recovery, was in a state of great despondency. The sedative 
solution of opium was subsequently given. She required only two 
or three doses, when the discharge ceased, and she ultimately reco- 
vered. 

Opium is almost indispensable when the system is very much 
reduced by haemorrhage, from whatever part of the body the blood 
may have issued : it allays that peculiar irritability and restlessness 
— prevents irregular determinations of blood, which are always most 
dangerous in this state of the system, and to which there is a strong 
tendency — and lastly, produces quiet, refreshing sleep. When the 
system is fairly brought under the influence of the drug, the strength 
is no longer exhausted by continual efforts to vomit, and by unceas- 
ing jactitation ; it sends the whole system to sleep, if I may be 
allowed the liberty of using such an expression, and enables it to 
live on a small scale of vitality, which, in the mean time, is enlarged 
by the judicious and frequent introduction of small quantities of food 
into the stomach to recruit the strength. Taking this view of the 
action of opium in such cases, we are enabled to account for the 
loose expressions used in books respecting it. For instance, Mr. 
BonM says: ''The strength must be supported by liberal doses of 
Opium:" and it will be found that this gentleman and others also 
■peak of a considerable dose of this drug as a stimulant. 

Practitioners are sometimes not sent for till the symptoms of de- 
bility arc extreme. Not a moment should be lost in these eases in 
plugging the passages either with pieces of soft sponge, or a lung 
stripe of old linen or cotton ; but our dependence is not to be placed 
on this alone; il is only done to prevent further loss in the mean 
time. 

Supposing the immediate danger over, and the discharge checked, 
the practitioner must consider what line of treatment ought to be pur- 



804 MENORRHAGIA. 

sued in the interval, because it may return again and again, if some 
effectual means be not taken. The treatment must depend on pecu- 
liarity of constitution; plethoric patients are to be treated very differ- 
ently from those who are feeble and weakly. General blood-letting 
is only necessary in the former, when it is found desirable to restrain 
the impetuosity of the circulation instantly; if not, it is best to reduce 
plethora by a rigidly abstemious diet, and the daily exhibition of 
saline medicines, containing, perhaps, a minute proportion of tartrate 
of antimony, together with a due quantity of exercise in the open 
air, and avoiding heated rooms, the use of feather beds, and too 
many bed-clothes. 

In debilitated habits, the diet should be nourishing, easy of diges- 
tion, and dry; all slops, whether in the shape of soup, jelly or gruel 
are to be abstained from ; the extremes of heat and cold are to be 
avoided, and great attention must be paid to preserve the extremities 
in a proper degree of temperature. The employment of the shower- 
bath is very desirable in all cases, except those in which extreme 
debility has been induced; the water should be used at first tepid, 
and is afterwards to be gradually brought down to the temperature 
of the season. Stimulants are serviceable in many cases, and in some 
are indispensable; tonics may also be administered when necessary. 

Astringent injections may be thrown into the passages, and are, no 
doubt, often serviceable; but in this country, there is a great reluctance 
on the part of women to use them, and when used, the operation is 
so often bungled, that I seldom speak of them to patients affected 
with menorrhagia, unless considerable relaxation of the parts exist, 
or the case be complicated with excessive leucorrhoeal discharge. 
Their employment in extreme cases is inadmissible, from the fatigue 
occasioned by the operation. 



CESSATION OP THE MENSES. 

When women arrive at that period of life when the menses should 
cease, the discharge generally becomes irregular, sometimes obstruct- 
ed for a time and again returning. Nausea and vomiting, particu- 
larly in the morning, swelling of the abdomen and .tenderness of the 
breasts occasionally take place; which symptoms sometimes induce 
a belief that women are pregnant, when, in fact, their constitutions 
are undergoing a natural change. Occasionally there is consider- 
able uterine pain, with a dragging sensation in the back and groins, 
some fever, violent headache, with a full, strong pulse, irregular state 
of bowels, loaded tongue, thirst and other symptoms of deranged 
digestion, and occasionally active haemorrhage from the uterus. 
These circumstances, particularly that last mentioned, frequently in- 
duce a belief of cancer, when it does not exist. It is, however, an 
undoubted fact, that scirrhus both of the mammae and uterus fre- 
quently occurs about the termination of the menstrual life; and indeed 
if the patient have any predisposition to organic disease, it becomes 
lighted up, and the affection then generally runs a rapid course. The 
belief is so general as to the critical nature of the cessation, and the 



MENORRHAGIA. 805 

dangers which attend this important change in the female constitu- 
tion, that women usually become apprehensive of themselves, and 
despond ; and whether they suffer or not, many have recourse to 
quack medicines, which are constantly advertised, and which they 
take to endeavour either to prolong the discharge, or to ward off 
disease. It cannot be too generally made known, that many females 
suffer from this imprudent conduct, and create diseases which, in 
all probability, never would have assailed them, had they taken pro- 
per medical advice. Dr. Denman, one of the wisest and most con- 
scientious men that ever adorned the profession, states that he 
"hardly recollects an instance in which such medicines did not do 
mischief." 

It is proper to mention, that many women suffer no particular in- 
convenience at this period; some enjoy better health than formerly, 
and become embonpoint, particularly those who have previously 
suffered from dysmenorrhoea. 

Treatment. — When the symptoms are slight, the treatment is 
very simple, attention to the diet and bowels, warm clothing, to- 
gether with proper exercise, being all that is necessary, and are, in 
general, sufficient to prevent any organic mischief. If any particular 
organ shows symptoms of suffering, appropriate remedies are to be 
had recourse to; but if there be general constitutional disturbance, or 
signs of uterine disease, particularly if the pulse be strong and firm, 
bleeding in moderate quantity will generally do good, and is to be 
repeated or not according to circumstances. The necessity for it is 
to be judged of principally by the appearance of the blood, the state 
of the pulse and the constitution of the patient. In cases where gene- 
ral bleeding is either inadmissible or its effects doubtful, we can have 
recourse to cupping the lower part of the back, or the application 
of leeches somewhere in the pelvic region. We must recollect, that 
when there is a tendency to local disease at the cessation of the men- 
strual discharge, it is, in general, of an inflammatory nature; therefore 
the di.it and other treatment must be regulated accordingly. Although 
it is by no means necessary, and, in many cases, would he improper 
to confine patients to the house, yet they must be careful not to ex- 
pose themselves to cold and damp, and they must particularly guard 
BgaiQSt the possibility of cold 11'!. 



CHAPTER XIV. 
DISEASES OF THE OVARIA. 



The Ovaria are subject to several diseases, as dropsy, scirrhus, 
vascular sarcoma, atrophy, and the formation of fat, hair, teeth, and 
bone. Of these dropsy is the most frequent, and this article shall be 
principally devoted to that disease; because it is difficult, if not im- 
possible, to discover the existence of the other morbid alterations 
before death, and if discovered, no treatment has hitherto been de- 
vised which holds out any prospect of success. 

Dropsical ovaria differ very much in external appearance, as well 
as internal character ; sometimes there is one large sac like a blad- 
der, at other times the disease consists of many cysts varying in 
number and size, very often one within another, like nests of pill- 
boxes, from the smallness of a pea to such a great size as to contain 
two quarts of fluid, and even two or three gallons. The cysts are 
sometimes divided by fleshy or cartilaginous matter, or by indurated 
cellular substance; and if I know what scirrhous structure is, I have 
most undoubtedly seen it surrounding some of them. The thickness 
of the walls of these cysts is various ; they are sometimes as thin as 
a hydatid, but more frequently like the urinary bladder; at other 
times they are an inch or two in thickness. The contained fluid is 
sometimes limpid and colourless, and without odour; at others it is 
viscid, ropy and dark-coloured, and occasionally has a disagreeable 
smell. In one instance, it was the colour of port-wine, flaky and 
fetid: in a number of cases which have fallen within my observa- 
tion, some of the sacs contained a matter so like calf-foot jelly, that 
it was impossible, from the appearance, to say it was not that sub- 
stance; while in others it was whitish, like honey after exposure to 
intense cold. Cases have been described, particularly in the Philo- 
sophical Transactions, of ovaria filled with hydatids, but I believe 
the bodies so called have generally no pretensions to the name; no 
one, as far as I am aware, has ever been able to trace a single vessel 
on the true hydatid, whereas, in the diseased ovaria, the sacs are so 
very vascular, that without being injected, vessels containing blood 
may be traced arborescing over them. Some cases are related in the 
Philosophical Transactions, and there is one in Haller's works in 
which the ovarium and its contents weighed above one hundred 
pounds;— the largest I have ever seen removed from the body after 
death, weighed twenty-five pounds, but they are rarely above twelve 
or thirteen. 



DISEASES OF THE OVARIA. 807 

These diseases of the ovaria are sometimes slow, at other times 
quick in their progress; or they may be slow for a number of years, 
and then, from some slight cause, and often even without any appa- 
rent reason, become more active, and destroy the patient's life in a 
few months, and sometimes even in a few days. 

This class of diseases is often complicated with affections of the 
uterus, such as tubercles, or even scirrhus and cancer : and in one 
patient, whose body I opened, both ovaries were diseased ; the one 
contained fatty matter and hair, the other was in a state of vascular 
sarcoma, and considerably enlarged ; the uterus, more than double 
its natural size, was also in a state of vascular sarcoma, and there 
were likewise ulcerations on the lips of the os uteri, as well as within 
the cervix ; but they were not of a carcinomatous character. These 
ovarian tumours are always covered with the peritoneum, and are 
often found adhering extensively to the surrounding parts, in conse- 
quence of the supervention of inflammation, and I have sometimes 
seen them adhering at almost every point. 

On opening the bodies of individuals, several of them of children, 
to ascertain the cause of death, some of whom had died of pneumo- 
nia, others of hydrocephalus, and many of bowel-complaints, I have 
occasionally observed vesicles, some the size and shape of small 
grapes, others like large currants, and attached, by a long pedicle, to 
the broad ligament in the neighbourhood of the ovarium. They 
sometimes existed solitary; at other times two or three might be 
seen suspended from one broad ligament, of which there are several 
specimens in my museum. I recollect having seen several vesicles 
attached by long and narrow pedicles to the peritoneal coat of the 
left ovarium in a child between two and three months old, who died 
from having been accidentally overlaid by its nurse. These vesicles 
are sometimes very vascular, and when enlarged, I have reason to 
believe, have been often mistaken for ovarian diseases. 

It is impossible to determine the exact time of life at which dis- 
eases of the ovaria may commence; but the fact is well ascertained 
that they never have been known to create local or constitutional 
disturbance, or to obtain any great size, till after the twentieth or 
twenty-first year. 

Symptom* qf diseases of the ovaria. — These diseases are seldom 
detected till, from their increasing size, they press on surrounding 
parts, or produce peritoneal inflammation, and thus create constitu- 
tional symptoms. In some eases, although the enlargement is con- 
siderable, the patient may not complain of pain: and, but for the 
weight of the tumour, and the mechanical pressure upon the bladder 
and rectum, occasionally producing strangury and piles, some wo- 
men with ovarian disease would suffer very little uneasiness. In 
other instances, acute, pain Attends the disease from a very early 
period, and it is the first circumstance which occasions a suspicion of 

disease. The pain comes and g i, and streets not only the lower 

part of the belly, but shoots into the groin and down the thighs. 

Frequently it is found, by comparing the appearances discovered on 

dissection with the history of the ease, that the attacks of pain have 
been owing to peritoneal inflammation, as proved by the existence 



808 DISEASES OF THE OVARIA. 

of adhesions, some of old standing, others bearing the marks of re- 
cent formation. The menstrual discharge is rarely suppressed, or 
otherwise affected than having been sometimes observed to be more 
profuse than natural, and to take place at shorter intervals. The 
functions of the stomach are frequently involved, sometimes giving 
rise to ordinary dyspeptic symptoms, particularly nausea and vomit- 
ing, as in the early months of pregnancy I have seen the mammae 
become enlarged and tender, in proportion as the tumefaction of the 
abdomen increased ; the nipple at the same time having the dark 
areola round it, which is considered so characteristic of pregnancy. 
Patients occasionally suffer very much from severe headaches and. 
violent hysterical symptoms. 

If we examine per vaginam, the tumour may sometimes be felt 
between the vagina and rectum, particularly before it becomes very 
much enlarged ; and also when it happens to be lodged in that cul- 
de-sac formed by the peritoneum, as it is reflected from the rectum 
over the posterior surface of the uterus. In such a case, the os uteri 
will be found tilted forwards close to the symphysis of the pubis, and 
we shall be liable to mistake the disease for retroversio uteri; but, 
in general, an examination by the rectum will undeceive us. As the 
tumour enlarges, it will ascend out of the pelvis, perhaps high up 
into the cavity of the abdomen, occupying its centre, and having a 
very close resemblance to the gravid uterus; at first, however, it will 
be felt in one of the iliac regions, about the size of an orange; but 
if the patient be fat, it may be impossible to discover it even when 
much larger. I have seen several cases where the tumour nearly 
filled the cavity of the abdomen, thereby simulating ascites, with 
which, indeed, it is sometimes combined, as in a case recorded in the 
8th vol. of the Medical and Physical Journal, in which there was 
about a gallon and a half of fluid found in the abdomen ; both ova- 
ria were enlarged so as to weigh together one hundred and two 
pounds. With respect to the feeling of fluctuation, in these cases, I 
know nothing in the practice of the profession so difficult to deter- 
mine. I have seen a solid tumour of the uterus which weighed above 
fifty pounds, the whole anterior surface of which was attached to the 
parietes of the abdomen, and notwithstanding which^the feeling of 
fluctuation during life was thought to be so distinct, that the woman 
was tapped three times, once by Dr. Scott in the presence of Mr. 
Marshall and myself, a second time by Dr. Duffin, at the suggestion 
and in the presence of the late Mr. Wishart; and a third and last 
time the operation was performed, I have the mortification to say, 
with my own hands, in the presence of Dr. Christison, and upon the 
assurance of the most eminent men in Edinburgh that there must 
be a fluid somewhere. I remember well borrowing the longest tro- 
car that could be obtained for the purpose, but the operation proved 
to be as dry a tapping as the others. Some little time after that oc- 
currence, I was asked to see a woman with a large abdomen, who 
had been previously tapped under the notion that she was affected 
with ascites ; no fluid followed the puncture ; some hours afterwards 
peritoneal inflammation took place, of which she died in a few days. 
When the pain first came on in the belly, the patient was examining 



DISEASES OF THE OVARIA. 809 

the wound made by the trocar; she accidentally coughed, and a 
small quantity of matter like jelly was discharged; she then made 
additional attempts by pressing and coughing to get rid of more, 
and a considerable quantity was thus evacuated, but without relief. 
When I saw her she was moribund ; and on dissection an ovarian 
disease with sacs containing a gelatinous matter was found, filling a 
great part of the abdomen, and extending a little above the umbili- 
cus ; the mark of the trocar was observed in the superior part of the 
tumour, the anterior surface of which was free, but so extensive 
were the adhesions behind, that it occupied me fully half an hour 
in dissecting the morbid parts carefully out, during which many large 
blood-vessels were divided. 

Treatment of ovarian disease. — In the exercise of our profession, 
nothing is more disagreeable and even humiliating than to be obliged 
to witness, from day to day, for a period of months or years, the suf- 
ferings of patients under a disease like this, without being able to do 
more than to palliate symptoms by means of narcotics. Sometimes 
we have the additional mortification to find that temporary tranquil- 
lity is produced at the expense of increased after-suffering; so that 
there really is something to tempt an individual, with an enterprising 
spirit, to the performance even of the horrible operation of opening 
the abdomen from the ensiform cartilage to the pubis, in the hope of 
being able to effect a radical cure. This operation has now been 
performed several times by Mr. Lizars,of Edinburgh ; and I have no 
doubt, from his anatomical knowledge and experience in operating, 
it was done in all the cases with the greatest dexterity, and that no 
means were neglected that could ensure success. But mark the re- 
sults : 

In one operation nothing was discovered but flatus in the intes- 
tines, and the woman died in forty-eight hours. 

In another who was affected with curvature of the spine and lum- 
bar abscess, after the abdomen was laid open, the uterus and ova- 
ria were found sound and healthy, but it was discovered that the 
woman was very fat. This woman escaped with her life at the 
time, although stated to be "often severely tortured with pain," but 
is still alive. . 

In a third operation, the subject of which also laboured under as- 
cites, Mr. Li/.ars took away a considerabl e fl ia o d tumour on the left 
side, but was forced to leave one on the opposite side untouched, 
from the extent of its adhesions to surroiuiding parts, the uterus being 
also a little enlarged. This woman survived the operation, but died 
three years afterwards. 

In a fourth case, Mr. Li/.ars took away a tumour by separating 
adhesions between it and the viscera; and the woman died from 
mortification. 

in the fifth ease, Mr. Lisart cul open the abdomen and fonnd a 
very large tumour, so completely attached to surrounding viscera, 
with so many large Mood*vesSels in the way of completing the ope- 
ration, that he was forced to abandon it, and to Btiten up the abdo- 
men. Uut in justice to Mr. Li/.ars, I may mention, that he main 
68 



810 DISEASES OF THE OVARIA. 

tained his coolness and self-possession, under circumstances which 
made the undaunted heart of the late Ur. Dease shrink within him; 
and it may be mentioned, that he was one of the best and most suc- 
cessful operators that the British army ever had to boast of. This 
woman survived the operation, and is still living. 

In a sixth case, upon which Mr. Lizars operated at Dumfries, he 
cut away a tumour projecting from the fundus of the uterus, which 
was thought to be an ovarium, but the woman died in a few days 
from inflammation, when the ovaria were found quite snug and 
sound in their proper situation. 

After giving this simple statement, I shall content myself with lay- 
ing before young practitioners the reasons why I consider this opera- 
tion unadvisable. 

1. It is difficult to tell whether there be a tumour or not in the 
abdomen ; and it will be remarked, that, in two out of six of Mr. 
Lizars' cases, no disease was found to account for the tumefaction of 
the abdomen. 

2. If there be a tumour, it is impossible to determine whether it is 
of the uterus, ovaria or some other part. Not long ago, one of my 
pupils attended a woman most assiduously during a whole winter, 
who had an enlarged abdomen, and I had no doubt, after making the 
necessary examinations, that the great enlargement was produced by 
ovarian disease. Externally, there was felt a large hard tumour on 
the right side of the abdomen, as if it had risen out of the pelvis, and 
from feeling the os uteri tilted up towards the right side of the pelvis, 
it appeared still more certain that the disease was ovarian. It was 
understood that many other medical men had pronounced a similar 
opinion, and that an operation had been proposed to her, which she 
was averse to, but resolved to abide by my opinion, which was 
frankly given, that she ought not to submit to it. Besides the uncer- 
tainty of the operation itself, and the dangers which necessarily 
accompanied and followed it, she was affected with one of the worst 
forms of epilepsy that had ever come under my observation. The 
woman followed my advice, but in the course of six months expired 
during an epileptic fit. On dissection the uterus and ovaria were 
found quite healthy, but the liver was enormously enlarged, and so 
elongated that it extended into the cavity of the pelvis: it was this 
organ which had occasioned the tumefaction of the abdomen. 

Some years ago I attended a very amiable and interesting young 
lady along with Dr. John Qairdner, of this city, who laboured under 
a very complicated set of disorders, which baffled our skill to cure, 
and we advised her to go to London, where she had a brother a 
medical man. One celebrated individual, who has figured in ovarian 
operations, most unhesitatingly pronounced her complaints to arise 
from disease of the ovarium, which Dr. Gairdner and I were per- 
suaded did not exist. Some time afterwards she died at Newcastle, 
and on opening the body, the uterus and ovaries were found per- 
fectly sound, but extensive disease was discovered in the stomach, 
colon, liver and kidneys. 

3. It is impossible to tell whether a diseased ovarium is attached 



DISEASES OF THE OVARIA. 811 

to surrounding parts, which must always be an insurmountable 
objection to an operation ; for should there be extensive adhesions 
which require to be separated during the operation, such a separa- 
tion, whether affected by the knife or by the fingers, must seal the 
fate of ninety-nine women out of the hundred. Even in the dead 
body, I have been occupied more than half an hour in separating an 
ovarian tumour from its adhesions, and removing it from the body, 
which was not affected without wounding many large blood-vessels; 
and the following description is given by Mr. Lizars of one of his 
own operations : — After opening the abdomen from the sternum to 
the pubis, "a multiplicity of convoluted vessels presented themselves, 
of various magnitude, from the thickness of a finger to that of a crow's 
quill. At first I thought them the intestines, for they appeared 
extremely fleshy ; then I imagined them the blood-vessels of a pla- 
centa, which they still more resembled; indeed, such was their re- 
semblance to the vessels of that organ, that the same idea struck one 
and all of the gentlemen present. On minute examination, however, 
they were found to be the blood-vessels of the omentum majus, 
enormously enlarged, running on the surface and into the substance 
of the tumour, which appeared an enlarged ovarium. Finding that 
it was impracticable either to dissect these vessels from the surface of 
the tumour or to secure them, in consequence of their great number, 
I abandoned the idea of extirpating the mass, in which decision I 
was supported by the gentlemen present; I therefore punctured with 
a large trocar and canula the centre of the tumour, but nothing 
flowed; I next made a small but deep incision with a scalpel, when 
the tumour appeared solid and cartilaginous, and a vessel bled a 
little; I lastly punctured the lower part of the tumour, being anxious 
to reduce its bulk, but only pure blood flowed. The lips of the 
wound were now approximated and stitched, adhesives straps ap- 
plied, compresses of lint and linen, with a shawl as a binder, and the 
patient was carried to bed. This operation was performed in the 
presence of James Dease, Esq., Surgeon to the Forces; Drs. Poole, 

, and Millar; Messrs. .lames Scott, George White and many 

other surgeons and students." 

In Mr. Lizars' case of Isabella C , he succeeded in insu- 
lating a large mass weighing upwards of Beven pounds, which he 
•• found adhering bo Btrongly to ihe parietes of the abdomen, to the 
colon, and to the brim of the pelvis, that l despaired (says he,) of 
being able to detach il ; however, by dissecting at one nun', and tear- 
cautiously with the fingers a( another, I succeeded," &.c. She 
died at 7 o'clock in the evening of die second day. 

i. it ought to be considered whether the dangers arising from 

the operation are not greater than from allowing the disease to re- 
main DndistUrbed In the firsl place, we have to consider the chance 

of the patient dying immediately from the shock, or from haemor- 
rhage, or subsequently from inflammation, after she has undergone 
the horrid torture occasioned by an incision from the sternum to ihe 
pubis, independently of thai produced by exposing and handling the 

viscera, and cutting away the tumour, not to speak of the dilliculty 



812 DISEASES OF THE OVARIA. 

of restraining the protrusion of the intestines, both during the per- 
formance of, and subsequent to the operation. " I shall never forget 
(says Mr. Lizars,) the countenances of my pupils, and the younger 
members of the profession, when the intestines protruded, and 

baffled all the efforts of Dr. and other gentlemen to confine 

them. The diaphragm acted with great vigour, and with powerful 
impetuosity." 

To give my opinion in the shortest possible manner, I shall sim- 
ply state, that I regard a recovery after such an operation as almost 
miraculous, and to be considered more in the light of an escape than 
a recovery to be expected, particularly if performed with an exter- 
nal incision through the parietes of the abdomen and peritoneum, 
from the ensiform cartilage down to the pubis. 

There is only one case in which an operation should be attempted 
— when we are consulted early, and find a tumour just above the 
brim of the pelvis, which is movable, and falls from side to side, 
when the patient changes her posture — when it is ascertained, after 
careful examination, both by the vagina and the rectum, that the 
uterus is, in all probability, sound — when the patient has as yet had 
no pain or constitutional symptoms, indicating the existence of peri- 
toneal inflammation, which may lead us to believe there are, as yet, 
no adhesions between the tumour and surrounding parts — and when 
the patient appears to have great courage and stamina, and as many 
lives as cats are figuratively represented to possess. In such a case 
I would recommend an operation, with an external incision barely 
large enough to admit the passage of a small hand to examine the 
disease, and bring the surface of the tumour to the opening, that its 
size may be diminished by tapping if necessary, when the sac can 
be drawn out by degrees, very much in the manner represented to 
have been pursued by Dr. Macdowal, of Kentucky. 

It is difficult to say what line of treatment ought to be adopted in 
diseases of the ovaria; but I shall state that which I have found to 
be most beneficial in these unfortunate cases. It is indispensably 
necessary to attend to the state of the bladder, by taking care that it 
be not over-distended, and that any irritation which may occasion- 
ally arise in this organ be mitigated by camphor and hyoscyamus, 
together with fomentations applied to the lower part of the abdo- 
men; the bowels are to be daily evacuated, if necessary, by mild 
laxatives, assisted by tepid water injections. Considerable relief is 
often experienced from the repeated application of leeches and con- 
tra-irritants, which operate not only by mitigating pain, but by stop- 
ping the advancement of peritoneal inflammation, which is so apt to 
occur, and also by arresting the progress of the diseased growth. 
Occasional opiates are also serviceable. The use of diuretics cannot, 
I think, be upheld in the true ovarian disease, as they can have no 
effect either in promoting absorption, or preventing a further collec- 
tion of fluid in the sacs ; neither can I fancy that iodine in any of 
its forms can have the effect of causing absorption of such diseased 
masses as I have seen the ovaria to consist. 

The next important question comes to be— Is the operation of 



DISEASES OF THE OVARIA. 813 

tapping these tumours likely to prolong life? Experience obliges 
me to say, that in general it is not, although there may be exceptions 
to this. Tapping, in such cases, is an uncertain operation, from the 
obscurity which generally hangs over them; and it may prove the 
first exciting cause of peritoneal inflammation, which niay quickly 
produce death, or leave extensive adhesions between the tumour and 
surrounding parts. I have already shown, by the description of two 
cases in which tapping was performed, how uncertain are the indi- 
cations for the operation; and I ktiow of one case, where the ope- 
ration of paracentesis abdominis was performed, under the idea of 
the existence of ascites, when there was actually no fluid. Feculent 
matter came through the canula, instead of the watery effusion ; the 
woman soon expired, and dissection showed that the trocar had 
penetrated the colon. But independent of these objections, which 
show, at least, that this operation, simple and slight as it appears to 
be, should not be recklessly performed, diseased ovaria are generally 
composed of such a number of cysts, that when a puncture is made, 
either no fluid at all, or only a small quantity, may be discharged, 
being the contents of one inconsiderable-sized cyst ; besides, I have 
found that the fluid is quickly secreted, and that the more frequently 
the operation is performed, the more frequently does it require to be 
repeated. Thus it will be seen in a case recorded at page 123 of the 
Medical Communications, 2d vol., that a patient was tapped forty- 
nine times from first to last, and two thousand seven hundred and 
eighty-six pints of fluid were drawn off; and it is stated that the 
secretion went on so rapidly at last that, by calculation, three pints 
and three ounces were secreted every twenty-four hours. Another 
case is recorded in the 74th vol. of the Philosophical Transactions, 
in which the patient was tapped eighty times, and the immense 
quantity of thirteen hogsheads of fluid were evacuated. Many 
other similar cases are to be found both in the English and Foreign 
Transactions, which incline me to agree with the opinion of the late 
Dr. Denmau — that the operation of tapping should at least be de- 
layed as long as possible, partly from i(s being an uncertain opera- 
tion, but principally because it is quickly followed by another accu- 
mulation, so that, in the course of a few days, the patient is in as bad 
a state as ever. 

I had nearly neglected to mention another proposal which was 
formerly made and carried into execution, with the view of ell'ect- 
ing a radical cure: it consisted in laying open the abdomen, and 
making an incision into the tumour, to evacuate the matter, and 
afterwards throwing in a stimulating injection, to excite inflamma- 
tion in the sides of the SBC, in order to produce permanent adhesion, 
or introducing a tent to keep the around Open until the fluid ceased 
to be discharged. A case is related by Dr. Houston, in the Philo- 
sophical Transactions, in which Ik; made an incision two inches long 
mto the ovarium, and evacuated a meat quantity of jelly-like matter 
and hydatids; the wound was afterwards kept open, and the patient 
is represented to have been cured, although the disease had existed 
for thirteen years, and occasioned violent pains. In the Memoirs ot 

68* 



814 DISEASES OF THE OVARIA. 

the Academy of Surgery, a case is to be found of a woman who 
was tapped for a large tumour in the belly, but nothing came away; 
an incision was then made into the tumour through the parietes of 
the abdomen, and thirty-five pounds of gelatinous matter were ex- 
tracted—next day fifteen pounds more were discharged, but vomit- 
ing and fever took place, and she died on the thirteenth day. I may 
add, that Dr. Denman notices the case of a patient who died on the 
sixth day after the sac was injected. 



PAET IX. 



GOUT.— RHEUMATISM.— SCROFULA.— DROPSIES. 



CHAPTER I. 
GOUT. 



This disease is sometimes known by the terms Podagra and Ar- 
thritis. Dr. Cnllen has divided it into four varieties: — 

" 1st. Podagra regularis, with decided inflammation of the joints, 
continuing for several days, and receding gradually, with swelling, 
itching and desquamation of the part." 

u 2d. Podagra alonica, with debility of the stomach, or some other 
internal part, and either without the expected or usual inflammation 
of the joints, or with slight and flying pains in them: with dyspepsia 
or other symptoms of debility often quickly alternating." 

" 3d. Podagra retrograda, with inflammation of the joints, reced- 
ing suddenly, and followed immediately by debility of the stomach, 
or of some other internal part." 

" 4th. Podagra aberrans, with inflammation of some internal part, 
preceded or not by inflammation of the joints ; if so preceded, the 
external inflammation quickly disappears." 

Dr. Mason Good has enumerated three varieties of gout : — 

" 1*/. Regular fit of gout," which differs in nothing from Cullen's 
first variety. 

" 2d. Disguised, lurking, atonic gout," which is nothing more than 
Cullen's second variety. 

" 3d. Complicated gout," in which he includes Cullen's third and 
fourth varieties, under the terms "retrograde, recedent, misplaced 
gout." 

Dr. Scudamore, who has written a large volume on gout, urges 
most potent objections, both nosological and practical, to these di- 
visions and the definitions attached to them. He divides gout into 
three varieties, viz.: acute, chronic and retroccdent ; and the following 
are his definitions: — 

"Acute gout. — Inflammation and pain of the articular, tendinous 
or bursal structure, usually attacking one part only at the same time, 
but in succession of attack) affecting dill'erent parts together; with 
preternatural folneSB of the adjacent veins, and in certain situations, 
with u:demaious swelling of the integuments, occurring in twenty- 
four or forty-eight hours from the invasion of the fit; vivid redness 
of surface, which is sometimes shining; entire disability of the af- 
fected part, with peculiar sensations of burning, throbbing, cutting 
and pricking, ami weight; the action sometimes readily changing 
situations spontaneously 01 from slight causes; terminating almost 



818 GOUT. 

invariably without suppuration, and usually with some critical indi- 
cations of the event." 

"Chronic gout. — Inflammation and pain more slight, irregular 
and wandering than in the acute; faint redness of surface; much 
permanent distension of parts, or continued oedema, and impaired 
moving power; without critical indications of its terminating; com- 
monly associated with a morbid state of the digestive organs, a lan- 
guid or oppressed circulation, and much nervous irritation in the 
system." 

"Retrocedent gout. — Metastasis, or transference of the gouty ac- 
tion in the paroxysm from the external part to some internal organ." 

It may appear a strange confession to come from me as a lecturer 
on the practice of physic, that I never read Dr. Scudamore's Trea- 
tise on Gout till actually engaged in writing this article, although I 
have long known that such a work existed, and that its author had 
attained a high degree of eminence in practice ; but I have several 
reasons in excuse to plead. 

It is impossible for a person engaged in practice, and at the same 
time most anxiously employed in investigating the nature and seats 
of disease, to peruse every medical work which now-a-days comes 
from the press. With respect to what had been previously written 
on gout, I had derived nothing but vexation and disappointment 
from the perusal. Very early in life, I had frequent opportunities of 
witnessing the phenomena, progress and termination of gout ; and 
during an attendance on a near and dear relative in the course of long 
paroxysms of this disease, I was compelled to read aloud, for his 
satisfaction and my own improvement, all the published works of the 
day. At last, when it was pronounced by a celebrated writer that, 
after all, the only thing to be done for gout was "patience and flan- 
nel" my patient became almost frantic with rage, and declared that, 
although he was not a physician, he could write more sensibly upon 
the subject himself, and concluded by desiring me to study nature 
and not books, if I wished to obtain a knowledge of the disease. I 
never forgot his advice ; and from that moment I began to make a 
book by storing facts in my own mind. 

When lecturing on gout, I have contented myself by giving a 
simple statement of all the pathological facts which I had observed, 
and by commenting on the statements made by Dr. Mason Good in 
his chapter on this subject; but after seeing Dr. Scudamore's treatise, 
it behoves me to state, that I have never been more gratified and in- 
structed from the perusal of any medical work ; and as the opinions 
which I entertain are similar in many respects to those of Dr. Scu- 
damore, I shall avail myself of many of his facts and observations, 
because they are drawn from a more enlarged experience. 

Phenomena of a Paroxysm of Regular Gout. 

"The gout, (says Cullen, Par. 492,) not only as it occurs in differ- 
ent persons, but even as it occurs in the same person, at different 
times, is a disease of such various appearance, that it is difficult to 






GOUT. 819 

render the history of it complete and exact, or to give a character of 
it that will universally apply." 

The first attack usually occurs in one of the feet, generally in the 
ball of the great toe, which has more or less of the appearance de- 
scribed by Dr. Scudamore in his definition of acute gout, and which 
there is no necessity for repeating in this place. The patient often 
attributes the sensation he experiences to a twist he thinks he has 
given his foot, or to the effects of a tight boot or shoe. Dr. Scuda- 
more says, at page 17: " On some occasions, and especially in the first 
fit, the immediate invasion of the disease is not preceded by any 
warning." The reason of this I believe is, that the warning has 
not been taken, as I have never yet seen a case which was not pre- 
ceded by a distinct announcement of gastro-intestinal irritation. The 
tongue has always a morbid appearance, being loaded, or having a 
fiery red colour, or being shrunk and blanched; the bowels are irre- 
gular; the patient feels loaded and oppressed after eating; there is 
acidity of stomach and heartburn which is sometimes excruciating, 
accompanied by occasional vomiting of a very acid matter. The 
epigastric region cannot bear pressure ; the urine is scanty, high- 
coloured, and becomes thick and muddy after standing. The patient 
is often observed to be depressed in spirits and drowsy, although he 
cannot sleep, and the nights are passed with great restlessness. The 
limbs are affected with numbness, weakness, and a pricking, tingling 
sensation, with cramps and darting pains along the course of the 
nerves, more particularly in the extremity in which the disease is 
afterwards to be fixed. The extremities at times can scarcely be 
preserved in the natural degree of heat; at others, they become 
burning hot, particularly the soles of the feet and the balls of the 
great toes, and these states alternate. There are sometimes general 
rigors, or rather fits of chilliness, followed by feverishness, during 
which the face becomes flushed, and there is sometimes headache. 

These precursory symptoms, and others which might be mention- 
ed, vary much in ditlerent individuals, depending upon idiosyncrasy. 
I have never known a person subject to gout who was not warned 
of an approaching paroxysm, by some sensation or symptom which 
might be said to ho almost peculiar to himself. Thus, one will have 
violent fits of sneezing;— a second, a feeling of heat and pain in his 
eyes, with a diminution of the lachrymal secretion ■— a third will pre- 
ceive heat, redness and swelling at the point of the nose; — a fourth 
will have a bronchial affection, with cough and slighl expectoration; 
— a fifth will he aware of the approaching attack' by a peculiar ap- 
pearance of the tongue, a feeling of coldness, heat or acidity in the 
Stomach, perhaps an unusual craving lor some particular kind of 
food; — a sixth is made apprehensive By the occurrence of diarrhoea, 
by unusual sloggishneas of the bowels, or flatulent distension of the 
abdomen; — a seventh will have great irritation about the. neck of the 
bladder, scalding in the urethra, and perhaps discharge of matter, 

sometimes p^mul; a little blood, and having slight difficulty in mak- 
ing water ; — an eighth will experience an nnnsnal lassitude, inability 

to apply his mind i<> any Subject, and irritability of temper, at tunes 
giving way to sudden hursts of passion, or merely to a feeling ot 



820 GOUT. 

peevishness; and a ninth will suffer from palpitation or some other 
symptom sufficiently striking to arrest his attention. Thoae who 
have experienced a few attacks of gout are hence able to take steps 
which will sometimes either postpone the paroxysm, or mitigate its 
violence. 

At length the paroxysm fairly sets in with the following local 
symptoms: — pain, which soon becomes burning and throbbing, with 
occasional stounds from the affected part up the limb, the return of 
which the patient constantly dreads; with some degree of swelling, 
which, as well as the pain, increases rapidly ; so that, in a few hours, 
the parts are much swollen, red, with considerable distension of the 
neighbouring superficial veins. Even from the first, a great part of 
the swelling is owing to oedema, for the parts will be found early in 
the disease to pit slightly on pressure. The redness soon becomes 
of a bright scarlet hue, and the throbbing, shooting pains, heat and 
inability to move the limb rapidly increase, so as to be at their acme 
in a first fit, perhaps in the course of twenty-four hours. 

First attacks are, in general, although not always, slight, the pa- 
tient being able through the day to bear his sufferings at least with 
composure. At night the pain and general fever increase, but decline 
again towards morning, with a slight relieving perspiration, at which 
time, perhaps, the patient enjoys a little slumber. 

The constitutional symptoms which occur during the paroxysms, 
vary not only according to the severity of the local inflammation and 
pain, but also to the state of health in which the patient may happen 
to be at the time. If there be any organic affection, of course the 
symptoms will suffer modification, which, however, falls to be con- 
sidered under the head of retrocedent gout. The first constitutional 
symptom which naturally attracts attention is fever, and in all old- 
standing cases of gout the disease makes its approach with chilliness 
and cold extremities, succeeded by some degree of fever and its 
usual attendants — restlessness, thirst, want of appetite and precor- 
dial oppression. The pulse varies ; it is generally full and hard, and 
indicates an inflammatory and plethoric state of the system, unless 
the patient be reduced in health and strength by the long continuance 
of previous organic disease or intemperate habits. Even in slight 
cases, the digestive organs show much functional suffering; besides 
want of appetite and thirst, the patient experiences abdominal pains, 
which are owing, perhaps, in nine cases out of ten, either to some 
indigestible matter lodged in the stomach and bowels, or to their 
flatulent distension, but which are too often attributed to cramp and 
spasm, and opiates or stimulants are exhibited. In many cases, burn- 
ing pain, or merely a sensation of heat is experienced in the epigas- 
tric region, where pressure cannot be well borne, accompanied by 
sour eructations, or vomiting of a very acid and acrid matter, which 
produces a sense of heat and rawness in the oesophagus. This matter 
sometimes looks as if mixed with bile, of a green colour ; at others, 
it is limpid and colourless. The tongue is furred, red round the 
edges, or it is clean, but of a fiery red colour, with the papillae much 
raised; but a furred tongue is the most common appearance, being 
either white, or having a yellowish tinge. The bowels are some- 






GOUT. 821 

times affected with looseness, but far more frequently they are torpid, 
and the evacuations are fetid, and look very vitiated and unnatural, 
being frequently mixed with mucus, which sometimes appears in 
shreds. The urine is scanty, high-coloured, producing irritation in 
the bladder and heat in the urethra, with their attendants, frequent 
desire to make water, and some degree of difficulty in doing so. On 
standing, a pink or brick-dust sediment takes place in every case 
during the inflammatory stage. The urine is often mixed with 
mucus, and is represented to be of greater specific gravity than 
when in a healthy condition. As the inflammatory symptoms sub- 
side, the urine loses its high colour, and by degrees ceases to deposit 
a lateritious sediment; but in its place there is a whitish deposit, as 
if it were mixed with a small quantity of chalk or magnesia. Dr. 
Scudamore thinks that the brick-dust sediment depends on the func- 
tions of the liver; and there can be no doubt that it has a share in 
the cause, but it is quite as likely to depend upon functional derange- 
ment of other organs, particularly of the stomach. 

The nervous system shows marked evidence of derangement, as is 
evinced by irritability of temper, general sensibility and restlessness, 
the intensity of the pain, the darting cramps extending along the 
course of the nerves, even throwing the muscles occasionally into 
violent spasmodic contractions, as well as by the sudden and instan- 
taneous translation of the inflammation from one limb to another. 

In the course of two or three days, the symptoms are found to 
have undergone considerable mitigation. The patient then com- 
plains of weakness in the limb, with perhaps slight tenderness of the 
part. It rarely happens, when gout may be said to be in its infancy, 
that the. inflammation, as it declines in one foot, appears in the other, 
or in any other joint, which circumstance is so frequently observed 
in the old-standing cases. 

The cedematous stale of the part continues for some days after he 
subsidence of the inflammation ; and occasionally, desquamation of 
the cuticle takes place, with much temporary itching. 

In one hundred and seven cases of the first attack of lout, Dr. 
Scudamore has given the following comparative statement, showing 
the parts most liable to be affected: 

In 70 cases, the inflammation was in one foot only. 

In 8, the great toe of each foot. 

In 2, the toe and instep. 

In 2, the outer side of one foot. 

In 1, the heel of each foot, the hand, and elbow. 

In 3, one ankle. 

In 1, each ankle. 

In 1, the ankle of one foot, and toe of the other. 

In :i, the ankle and instep of one foot. 

In 1, the toe, instep, and ankle of one foot. 

In i, instep of one fool. 

In 1, instep of each foot. 

In l,one instep first, afterwards each knee, wrist, elbow and 
shoulder. 

In 1, heel of one foot. 
69 



822 GOUT. 

In 1, heel of each foot. 

In 1, each foot and hand. 

In 1, right thumb, and afterwards in the toe. 

In 1, right knee. 

In 2, left knee. 

In 1, hand and wrist. 

In 1, back of one hand. 

In 1, back of each hand. 

In 2, one wrist. 

In the early fits of gout, the health improves soon after the local 
symptoms decline, and 1 have heard many people declare they felt 
themselves better and more vigorous than they had done for weeks 
and even months before. 

The gout may return annually, perhaps, at shorter intervals; on 
many occasions, however, there is no threatening of a paroxysm for 
several years; but as the disease goes on, the attacks are generally 
more severe, the fits longer and the intervals shorter, the parts af- 
fected more numerous, till at last the constitution becomes broken 
down. Dr. Scudamore has justly observed, that the frequency of a 
return of gout is in proportion to the constitutional tendency, and to 
the unfavourable mode of life of the individual. 

In subsequent attacks, the constitutional and local symptoms are 
similar in character to those already described, but are more marked 
in point of severity, of longer duration, and the constitutional nature 
of the disease becomes more and more manifest. The precursory 
symptoms are also rendered more apparent by becoming more severe 
with each returning fit. But we are assured by Dr. Scudamore, that 
even confirmed gouty subjects are sometimes attacked at the very 
moment when they most congratulate themselves on the possession 
of health and strength; and he has seen some fits thus sudden and 
unexpected, in the sequel very tedious and severe. 

There is no disease, except, perhaps, rheumatism, in which such a 
complete appearance of metastasis or translation of the inflammation 
takes place as in gout; the disease having been frequently observed 
to originate in the toe of one foot, at the very time it disappeared in 
the other. There can be no doubt of the fact, although, in many cases, 
I have been able to satisfy myself, that the inflammation in both feet 
had previously co-existed; but when it became more painful, and a 
greater annoyance in one foot, the attention was attracted from the 
other. In the same manner, a metastasis sometimes appears to take 
place from the great toe, or from any other joint, to an internal or- 
gan ; but this, I am also persuaded, is often a deception, and can be 
explained in a similar manner. 

Phenomena of Chronic Gout. 

When the constitution is considerably injured by long-continued 
indulgence in luxury and bodily inactivity, or is worn down by re- 
peated attacks of acute gout, the disease assumes a less violent, but 
still more dangerous form, which Dr. Scudamore has called "chronic," 






GOUT. 823 

— Dr. Cullen, "atonic,"— and Dr. Mason Good, "disguised, lurking, 
atonic gout." 

This form of the disease is generally a consequence of previous 
acute attacks. The local inflammation, pain and redness are com- 
paratively slight; there are more permanent distension, oedema and 
helplessness of the affected limb than in the acute form ; but the con- 
ditions of the digestive organs, of the circulating and nervous sys- 
tems, are more embarrassed and oppressed. The disease is more 
bearable in this than in the acute form, because the patient does not 
suffer that extreme agony occasioned by intense local inflammation; 
but there is, nevertheless, more danger, from the importance of the 
parts whose functions are very seriously impeded, which sooner or 
later terminates in structural lesion ; and it is invariably observed that 
the paroxysms are more frequent and irregular. 

According to Dr. Scudamore — "The slate of the constitution in 
chronic gout embraces a great variety of symptoms, which are mo- 
dified by the temperament and habits of the patient; by the situation 
and degree of local disease; and also by the seat and nature of the 
internal visceral derangement. Indeed, so many anomalies so often 
arise in this impaired state of the health, partly depending on internal 
causes, and partly on the painful or uneasy state of the affected tex- 
tures, that probably no description would be adequate to include all 
these shades of sympathy; and it may be sufficient to delineate a 
general outline."— (P. 327.) 

Some patients are severely distressed with dyspeptic symptoms, 
such as uneasy sensations in the stomach and bowels, nausea, a crav- 
ing desire for food, oppression and flatulent distension after every 
ordinary meal, which are much increased if the stomach be incau- 
tiously loaded. Some experience cramps, others heartburn, and 
some a peculiar coldness in the stomach, which they compare to that 
which would be produced if it contained ice. The cramps are owing, 
I am persuaded, in a great majority of cases, to efforts made by the 
stomach and bowels to expel crude and indigestible matters ; as well 
as to distension from flatus, and are not commonly, at least, of that 
mysterious nervous character which is generally imagined. Although 
the patient's appetite Beems natural, yet he is not nourished by his 
diet; he neither experiences increased Btrength nor vigour, but on 
the contrary, suffers additional constitutional and local irritation, and 
even feverish action. ll;s mind becomes weak and irritable, often 
hypochondriacal; he is haunted by imaginary evils during the day, 
and by disturbed, or even frightful dreams al nighl ; and the sleep is, 
in general, broken and unrefreshing. Palpitations are common, not 
only in the region of the heart, but in the course of the abdominal 
aorta, even when the heart's action is quite tranquil and natural. 
The body becomes more susceptible to the impressions of atmospher- 
ical vicissitudes ; the limbs become emaciated and weak when the 
abdone-n is, perhaps, growing larger ; the bowels are sometimes cos- 
tive) sometimes loose; the Btoola always possess an unnatural fetor, 
sometimes having ■ white appearance, showing a diminution of 

biliary secretion ; at other times Ihey are -In k en loured, and very fre- 
quently mixed with mucus. I have even seen the mucus tinged with 



824 GOUT. 

blood, and attended by all the usual symptoms of dysentery. There 
is considerable irritation about the rectum, no doubt often produced 
by the enlarged and painful condition of the hemorrhoidal veins, 
which occasionally discharge blood, sometimes in considerable quan- 
tity; and many gouty people are so much relieved by periodical 
haemorrhage, not only from the anus, but from the nose, that they 
consider it necessary to health; and I have known several cases in 
which apoplexy took place, when the natural haemorrhage ceased to 
recur. The urine has much the same appearances as in the acute 
form of the disease. A chronic cough and expectoration are fre- 
quently met with, and depend upon the state of the bronchial mem- 
brane. 

The calcareous depositions which are so frequently found about the 
smaller joints, and which go under the name of "chalk stones," are 
more frequently formed in this species of gout than the acute. The 
humoural pathologists believed them to consist of indigested gouty 
matter thrown upon the joints, and changed into their peculiar state 
of hardness by the heat and pain of the joint, but they are now 
known to be a compound of uric acid and soda. "These gouty con- 
cretions, (says Dr. Scudamore,) occurred only in a few individuals of 
particular gouty idiosyncrasy, and are found in various situations 
from within the synovial membrane of the joint even to the layers 
of the cutis. I have found them in the living subject, filling the 
bursa?, and condensed to great hardness; in the sheaths of tendons, 
feeling almost stony; in the cellular membrane, either in hard or soft 
lumps ; and under the cuticle, pressing for escape. In one gouty 
person who comes under my frequent observation, the concretions 
near the surface have caused numerous ulcerations both in the hands 
and feet, and the chalk-like matter is constantly secreted." 

Phenomena of BelroceJent Gout. 

It sometimes happens, that, during a fit of gout, the external in- 
flammation suddenly disappears, or, at least, becomes very much 
mitigated, while the patient is affected with lethargy, stupor, coma, 
apoplexy; or with severe pain in the head, and other symptoms in- 
dicating inflammation or some other cerebral affection. 

At other times, on the recession of the gout, difficulty of breathing, 
with tightness in the chest, great oppression at the prsecordia, and 
a sense of suffocation, followed by cough and expectoration, take 
place; or violent palpitation, pain and constriction in the region of 
the heart, accompanied by oppressed breathing, cough, &c, indicating 
disease of some part or parts of the viscera of the thorax. 

In another set of cases, the translation takes place towards the 
abdomen with symptoms of gastritis, hepatitis, enteritis, peritonitis 
or dysentery ; and, in some cases, the urinary organs are involved. 
Dr. Scudamore thinks " the transference is most disposed to affect 
the stomach or intestines, or both in succession. The symptoms 
which attack the stomach are exquisite pain and spasm, with vomit- 
ing. If the intestines be more distinctly affected, enteritis, m its 
worst forms, is produced; and vomiting, which is a usual attendant, 



GOUT. 825 

is more or less urgent, according as the seat of disease is near or dis- 
tant from the stomach. In either case, the danger is pressing; and. 
unless relief be speedily rendered, death soon closes the scene." 

Dr. Cullen (Par. 532) observes, that " the stomach, which has so 
universal a consent with the rest of the system, is the internal part that 
is the most frequently, and often very considerably, affected by the 
gout. The paroxysms of the disease are commonly preceded by an 
affection of the stomach ; many of the exciting causes act first upon 
the stomach; and the symptoms of the atonic and retrocedent gout 
are most commonly and chiefly affections of the same organ." 

Dr. Mason Good (vol. 2, p. 630, 2d ed.) makes the following ob- 
servations: " It sometimes happens, however, that while the general 
constitution of a podagric patient is tolerably sound, one or more of 
the internal organs form an exception to the general rule, and are less 
healthy than the rest. And as, upon an excitement of gouty inflam- 
mation in a gouty habit, the inflammation seizes ordinarily upon the 
weakest part of the body, it makes its assault upon such organ rather 
than upon the hands and feet; or, if it commence in the latter, is 
readily transferred to it; constituting the third of the varieties before 
us, and which has usually been called retrograde or misplaced 
gout. And if the general system should, at the same time, be below 
the ordinary tone of health, when the paroxysm is thus excited by 
the force of some occasional cause, the organ affected may evince 
great languor and painful inertness, as in the second variety, rather 
than acute inflammation, as in the first. The sensation in the sto- 
mach, instead of being that of a fiery coal, is that of a cold lump of 
lead ; in the head it changes from maddening pain to oppresive horror, 
in which the patient suddenly starts from sleep almost as soon as he 
has begun to doze from the hideousuess of the ideas that rush across 
the mind, and from the distracting dream. 

"The fit is sometimes transferred to the bladder, in which case 
then; are acute pain at the neck of the organ, strangury, and a dis- 
charge of thin acrid muctlS From the urethra. The rectum has also 
|y been the seal Of metastasis, and has evinced various 
species of affection, as simple vehement pain, spastic constriction ; or 
haamorrhoidal tumours. When thrown upon the lungs, it mimics 
the symptoms of a peripneumony." 

There it a great deal of good sense and sound observation displayed 
in the aboi . but it is mixed up with some absurdly mysteri- 

ous expressions, which may throw young practitioners off their guard, 
and therefore must l>e noticed, when Dr. .Mason Good speaks of 
the second variety of retrograde gout, in which the organ affected is 

represented to I below the ordinary torn- qf health, evincing 

great languor and painful inertness, instead of more violent symp- 
toms, as in the first variety," one accustomed to see much ol disease, 
and to "p" 11 ll1 '" bodies of those who have fallen victims to it, would 
be led t" imagine the author was not aware that inflammation may 

exist in varioii of intensity; and that, modified hy BOOM 

peculiar, but unknown Causes, inllainmation of similar intensity 
and extent will give rise in one subject to violent symptoms, while 
in another they have such an opposite character, that although the 

G9" 



826 GOUT. 

patient is observed to labour under some degree of suffering, yet the 
symptoms are not so striking as to attract the same degree of atten- 
tion. These passages would lead one to imagine that the author of 
this learned and laborious work was not aware that inflammation of 
different tissues gives rise to a different cast of symptoms as to vio- 
lence, which is particularly exemplified in the serous and mucous 
membranes, which last are so very frequently involved in gout. I 
must enter a strong protest against the expression used when speak- 
ing of retrocedent gout, viz.: "When thrown upon the lungs, it mimics 
the symptoms of a peripneumony." 

Dr. Scudamore states "that Dr. Home, of Edinburgh, in his lectures, 
relates the case of a gentleman who exposed himself to the influence 
of wet and cold when the gout was slightly present in the feet: and, 
on the same afternoon, enteritis followed, which in twelve hours 
proved fatal. He also states that Dr. Parry informed him, " that in 
the same winter he has seen two instances of extravasation in the 
brain, from the removing of gout in the extremities, by immersing 
the feet affected in cold water." 

Unless from similar rash practice, or from imprudence on the part 
of the patient, I conceive that such sudden translations of the inflam- 
mation, or, what is the same thing, sudden alterations in the balance 
of the circulation, during the paroxysm of gout, are among the rarest 
occurrences to be met with in practice, unless, indeed, there have been 
previous disease in the organ to which the translation takes place. 
A person of gouty habit may be seized, after exposure to cold and 
damp, with slight inflammation of the brain, lungs, or of any other 
organ, when his bowels are constipated and his system plethoric; 
gouty inflammation of a joint may supervene, and mitigate for a time 
the internal disorder, the attention of the patient and of the physician 
being then exclusively attracted to the external inflammation ; and 
subsequently, upon the subsidence of the inflammation in the joint, 
or from mismanagement, such as plunging the foot into cold water, 
the internal disease may reappear, perhaps with increased violence, 
or, what is all the same, when the patient is weaker, and not so well 
able to stand the remedies as he would have been a few days pre- 
viously. Or it happens that an individual may be affected with a 
permanent organic disease of the heart or lungs, and may be at times 
seized with gout, when he will be every moment in danger of the 
inflammation receding from the joint. I once casually met with a 
gentleman, in many respects a hypochondriac, and who was so con- 
sidered, at least according to his own account, by his medical attend- 
ant. He had a very foul tongue and acidity of stomach, which he 
said had been his constant companion for years; he also added that 
he had a tightness about his chest, which was certainly increasing; 
and that he never had a good night's rest, in consequence of frightful 
dreams. I satisfied myself from the state of the pulse, and that of 
the heart's action, that he had an enlargement complicated with dila- 
tation of that organ. In the course of a few months afterwards, he 
was seized with gout, and died during the attack from retrocession; 
his death was attributed by his medical friends to "spasm of the 
lungs;" whereas, all the symptoms immediately preceding death 



GOUT. 827 

appeared to accord with the opinion which I had formed to myself. 
I anxiously looked forward to the examination of the body of this 
patient, and took an opportunity of urging its propriety, but received 
the following reply — "What would be the use of opening a man 
who died of gout ?" 

In the year 1S30, I attended a gentleman who, after an illness 
which I knew to proceed from extensive disease of the heart, with 
which he had been slightly affected (or several years, was seized 
with gout in the lower extremities. The external inflammation was 
very unsteady in its seat, sometimes affecting one joint, sometimes 
another; but whenever there was little external inflammation, he 
became instantly affected with difficulty of breathing, occasioned by 
bronchitic inflammation or violent palpitations, with constriction and 
sense of suffocation. Twice the translation took place to the brain; 
on one occasion he became frantic, talked loud and abused those 
about him ; and on another, he exhibited a strong tendency to coma. 
At these times relief was produced by the application of leeches, but 
principally by causing external irritation. At last, after spending a 
quiet night, with much refreshing sleep, taking nourishment at proper 
intervals, and when every thing appeared to be going on well, he 
became affected with difficulty of breathing, and died in a moment. 
Immediately previous to the fatal event, he expressed his own satis- 
faction at the relief he had experienced and the prospect of a speedy 
recovery. I made every effort to obtain an examination of the body, 
but failed, in consequence of a promise he had extorted from his 
wife; but there could be no doubt that there was hypertrophy with 
dilatation of the heart, disease of the valves, and that there had been 
bronchitic inflammation. 

Causes of Gout and Pathological Observations. 

Dr. Scudamore has written a considerable number of pages on the 
causes of gout, to which I beg to refer my readers for a great deal 
of very valuable information, as it would be inconsistent with the 
plan of this work to enter so much at large into the subject as he has 
dotie in his treatise. 

The first question that naturally suggests itself is — Whether or not 
the disease is hereditary? According to Dr. Cullen, it is expressly 
defined to be — u Morbus hereditaria*, orient tine causa externa 
evidente" &c. Guided by nature instead of books, I have observed 
that gout is more an acquired than a hereditary disease. Dr. Scuda- 
more instituted an investigation to ascertain the fact, and of one hun- 
dred and thirteen patients, the number of those in whom the disease 
was hereditary from thfl father, amounted to 88 

mother* - .... 9 

, rather and mother, .... 3 

Of those whose grandfather only had gout, the disease 

completely hopping over OBS generation, 8 

grandmother only, 1 

— undo only, - ... 3 

aunt only, - 1 



Gout not known cither on the father's or mother's side, - 58 



828 GOUT. 

From this statement, it appears that the cases of acquired gout, in 
which no family reference could be traced, were to the rest as fifty- 
eight to fifty-five ; and in the examples contrasted with those imme- 
diately hereditary, as fifty-eight to forty-four. My own experience 
corroborates the above statements, but it is generally viewed as a 
hereditary disease; and this has arisen, I imagine, from the habit 
which too often obtains among medical men, of drawing general 
conclusions from one or two facts, such as the following. A gentle- 
man in affluent circumstances, very fond of the pleasures of the table, 
and taking little exercise, will generally be found to be afflicted with 
the gout ; and because his son, living exactly under the same cir- 
cumstances, perhaps enjoying greater indulgences, and being fully 
more indolent, also has the gout, it is marked down immediately as 
a strong proof of the hereditary nature of the disease. But if the 
case were somewhat altered, if the father, however gouty he might 
be, were to experience a reverse of fortune, and his son were ob- 
liged to break stones on the road, or to earn his bread by any other 
kind of severe labour, then there would be about a hundred chances 
to one, that, to whatever diseases he might be heir, he should never 
have the gout. 

Gout is notoriously a disease of the rich, or rather, I should have 
said, of the affluent and indolent, who induce a constitutional ple- 
thora by living in a too luxurious manner, pampering the appetite, 
and overloading the stomach with different articles of food at each 
meal — who do not take sufficient bodily exercise, or attend to the 
state of their bowels — and who stimulate their systems in every pos- 
sible way, till at length their bodies may be said to resemble a house 
filled with highly combustible materials, which requires but the ad- 
dition of a small spark to set it in flames. Dr. Scudamore observes 
that, in Scotland, gout is much more rare than in England, and that 
in Edinburgh, where the habits of the people approach the nearest 
to those of London, it is seen most frequently; while in Glasgow the 
gout is very rare, even among the highest classes, which he ascribes 
partly to the greater activity of the people and the better regulation 
of general habits; but he gives a sly hint, that the exemption may 
be owing also to the use of Glasgoiv punch, which is a more general 
beverage at the best tables than wine ! ! The truth undoubtedly is, 
that gout is comparatively rare among the middling ranks in Scot- 
land, and that it is not nearly so frequent among the rich as in the 
same class of society in England; and one cannot help feeling proud 
at being connected with a country whose population, from the high- 
est to the lowest, are bent upon giving their children a better educa- 
tion than they themselves have received. Many a man in a humble 
walk of life is delighted with the thought that one of his sons may 
possibly some day fill a pulpit, or be physician to some great em- 
bassy, or raise himself, by integrity and assiduity, to be a first-rate 
London merchant, or be sent to India, and become a rich nahob. 
These are far greater sources of delight to the humble Scotsman, 
than pampering his own appetites. It is thus he raises the moral 
and intellectual character of his country, and prevents himself from 
being teased and tortured by many a bodily infirmity. — A word re- 



GOUT. 829 

specting the Glasgow people and the Glasgow punch. I know that 
the statement made hy Dr. Scudamore is generally believed, but the 
truth is, we do not often meet with gout in Edinburgh in any class 
of society; and however unfrequent it may be in Glasgow, I am 
quite sure the habits of all classes of society in Edinburgh will at 
least stand a comparison with those of the inhabitants of that flour- 
ishing city. 

The gout attacks males much more frequently than females ; but 
some of the most severe and tedious cases of gout I ever attended 
happened in females ; and during the course of the summer of 1S30, 
a female had a severe attack, which was protracted for three months. 
She was very little benefited by any mode of treatment, till the parts 
affected were literally covered several times with leeches, after whicli 
she speedily recovered. 

With respect to age, it has been remarked from the time of Hip- 
pocrates downwards, that it is a disease which, if it ever do occur, 
is rare before the age of puberty. I have known one case in a boy, 
the son of a scientific friend, who, no doubt, had an attack of gout 
at an early age. As a general statement, the correctness of the fol- 
lowing paragraph from Dr. Scudamore may be depended on : — "I 
have not myself witnessed more than one example of a first attack 
before twenty, nor any after sixty-five." 

I have seen the gout attack individuals of every kind of tem- 
perament, complexion and disposition; and, with respect to severe 
study, I am sure this is much overrated by writers as a cause of 
gout. « This cause, (says Dr. Scudamore,) comprising not only want 
of exercise, lateness and irregularity in the hours of rest and sleep, 
but also its consequences, weakness of the stomach, and inactive 
bowels, by its effects on the nervous system from the over-action of 
the brain, produces that form of irritative debility which increases 
the susceptibility of the frame to disease, and consequently to gout, 
if such be the predisposition of the individual." I admit that people 
of studious habits, who eat and drink a great deal more than the 
wear and tear of the body require, will be liable to gout; but I do 
not consider it in any way connected with the over-action of the 
brain, Which is certainly more conducive to health and longevity 
than indolence of mind, all other circumstances being the same. For 
example, I know oik- gentleman most intimately, with a strong here- 
ditary title to tin: disease, who, for many years, has had his mind 
intensely engaged in scientific pursuits. During that period, he has 
scarcely ever enjoyed more than five hours sleep in the twenty-four 
— and Ins often been tun or three days and nights without being in 
bed, sometimes, indeed, four or five — Ins constant habit is to sit over 
the " midnight lamp" till two, three <>r Ibnr o'clock every morning; 
and yet, Were Ik- •j.mwj- to insure Ins life, he could obtain a policy at 
hall' the premium li 1 ' COtrid have done twenty years ago, with all the 

diflere ■ of age. H<- has preserved himself by rarely drinking any 

thing stronger than good table-beer ; avoiding loading Ins stomach ; 
and regulating tin' quantity of solid food to the exercise which he 
has enjoyed, the state of Ins bowels, and the degree of mental effort 
which he knows he must make after dinner. It may be mentioned 



830 GOUT. 

as a hint to others, that when he has to apply his mind most assi- 
duously, he prepares himself for the exertion, not by taking a very 
hearty meal and a more liberal allowance of wine, but by eating 
less than usual and taking no stimulant whatever, although he can, 
when necessary, enjoy his friend with a good dinner and a bottle of 
wine, as well as any other person. 

All excesses in eating and drinking are bad for the animal system, 
and render it liable to disease; but overloading the stomach with 
different kinds of food at every meal, is, I am persuaded, far more 
frequently the cause of gout than over-drinking. Nevertheless, 
every habit which tends to produce plethora, combined with irrita- 
tion of the stomach and bowels, may be considered as a cause of 
gout. There are some kinds of wines which, taken even in a mode- 
rate quantity, gouty subjects always feel — these are, more particu- 
larly, champagne, and claret. 

Upon the whole, then, I look to a diseased state of the mucous 
membrane of the stomach and bowels, as produced by all the above 
causes, either singly or combined, in addition to a plethoric state of 
the system, as being the cause of a gouty paroxysm. I believe that 
the seat of the gouty inflammation is in the nervous filaments of the 
part affected: but various opinions have prevailed upon this last 
point. Boerhaave considered a morbid texture of the nerves and 
capillaries to be the disease. The humoural pathologists supposed 
that it depended upon an acrimonious state of the fluids which are 
separated, and thrown off by a process of nature ; and they con- 
sidered the inflammation in the extremity to be a sign of a revulsion 
of the humours, and therefore regarded it as a mark of health. 

Dr. Cullen was of opinion that, "in some persons, there is a certain 
vigorous and plethoric state of the system which, at a certain period 
of life, is liable to a loss of tone in the extremities. This is, in some 
measure, communicated to the whole system, but appears more espe- 
cially in the stomach. When this loss of tone occurs while the energy 
of the brain still retains its vigour, the vis medicatrix natnroe is 
excited to restore the tone of the parts; and accomplishes it by ex- 
citing an inflammatory affection in some part of the extremities." 
(Par. 533.) Thus it will be perceived that here, as well as in fever, 
he makes strength to depend upon weakness, and weakness upon 
vigour and plethora of the system. 

According to the views which I have taken of gout, it should be 
regarded simply as an inflammation of the affected part, produced 
by an effort of the constitution to remove disease from internal parts 
to the surface of the body. Therefore, the inflammation of the toe 
is not to be regarded as a disease, but only as the occasional symp- 
tom of a disease, which may be one either of function or of struc- 
ture. This is proved by taking a retrospective view of the causes 
of gout, aud the marks of constitutional disturbance which always 
precede the inflammation of the part — by the production of a great 
increase of internal suffering, sometimes even death, from the sudden 
recession of the external inflammation — and by the universal belief 
of those who have either seen the disease or experienced its suffer- 



GOUT. 831 

ings, that a gouty paroxysm clears the system of something which 
had been acting injuriously upon it for some time. 

The body may be in a very high state of predisposition to take 
on gouty action, but it requires some additional accidental circum- 
stances to bring it into operation; this is what is called an exciting 
cause, of which there are many; but the following are the most fre- 
quent. Exposure to cold and wet, particularly when the body is in 
a state of fatigue; long-continued coldness of the extremities; con- 
stipation; indigestible matter taken into the stomach; a cold drink 
when the body is heated ; a particular act of intemperance, more 
especially, indulgence in the use of certain kinds of wines; excessive 
evacuations; suppression of periodical discharges; the influence of 
the passions, a strain, or pressure from a tight boot or shoe, &c. 

Treatment of gout. — In the treatment of gout, it is to be feared 
that much mischief is frequently done by large and repeated bleed- 
ings under the idea that this disease depends upon an internal affec- 
tion of an inflammatory nature. Injurious consequences have also 
followed from the opposite course of never bleeding; the practitioners 
treating the symptoms as the disease, which they supposed to possess 
some peculiar and mysterious character, rendering all interference 
hurtful, even dangerous, and therefore dooming the patient to Dr. 
Cullen's remedy of patience and flannel. Many highly respectable 
men still entertain this opinion ; and it becomes an important inquiry 
to ascertain how this should have come to pass. Many people are 
still guilty of pinning their faith to the sleeve of Cullen, never once 
calling their own good sense into action. Heroic remedies, if not 
loudly called for by threatening symptoms, undoubtedly do mischief, 
by interfering with the salutary operations of nature. Many prac- 
titioners, I am sorry to say, treat every disease which comes before 
them according to its name and not according to sound pathological 
principles, including the consideration of age, constitution, habits and 
duration of the disease. Some patients are therefore bled who do 
not require it, and the consequences are injurious; others are bled 
who cannot bear it, and who ought to be treated by cordials, and 
the result is fatal; many patients are over-purged with drastic medi- 
cines, to the aggravation of the disease, while others are bunged up 
with opium. Some pal nuts are highly nourished and over-stimu- 
lated, because the doctor thinks gout a disease of debility, which, in 
all cases, requires nourishment ; and as the heart is unable " to pump 
the blood to the brain, which may produce fatal syncope," the 
strongest stimulants arc necessary to effect that end. Such prac- 
titioners never alter their practice; they have one steady method of 
treatment for all cases. There are also reasons why the public in 
general entertain a dread of interfering with the course of a gouty 
paroxysm. It may be a prejudice handed down from lather to son, 
and the notion very probably owes its existence to statements made 
to that effect in medical writings. Hut the principal reason appears 
to be, that many people ruin their constitutions, and some even die 
suddenly, from being io the habit of going on indulging their appe- 
tites, because they know they can relieve themselves very speedily 
during a paroxysm, by the use of colchicum or the euu medicinule. 



832 GOUT. 

There is a very satisfactory method of explaining why gout should 
be imagined, by people unacquainted with medicine, to be ultimately 
conducive to health, and to rid the constitution of something noxious. 
Observing people perceive, that some constitutional ailments, such 
as indigestion and its attendants, always precede a gouty paroxysm; 
and that after the fit subsides, these no longer exist. Now this is 
no doubt correct, that the external inflammation has the effect of 
relieving the internal disease. But there is another circumstance 
which is not observed, or which is lost sight of, and that is, that per- 
sons who have suffered the agony attending a paroxysm of gout, 
subsequently, for a considerable time at least, avoid all causes which 
they know will expose them to the return of such a torturing visitor; 
they also attend to their bowels, and take more exercise. I know 
many, even highly predisposed persons, who have thus warded off 
the disease for years. 

Regarding the disease according to the views I have endeavoured 
to point out, the treatment is generally quite simple. 

In a first paroxysm of gout, and in all slight cases, little consti- 
tutional treatment is necessary further than keeping the bowels 
gently open by any mild laxative exhibited every six or eight hours, 
and restricting the diet to very small quantities of farinaceous food, 
or merely allowing thin gruel or arrow-root; and the best ordinary 
drinks are whey, barley-water, or toast-water. The patients are to 
be kept cool and quiet, and if the pain and inflammation of the 
affected part be slight, a tepid, evaporating lotion, composed of three 
or four ounces of tincture of camphor to a pound of water, is to be 
applied to the part, by means of linen several times folded and kept 
constantly wetted. This does not differ from the lotion recommended 
by Dr. Scudamore, which consists of one part of alcohol to three 
parts of the mistura camphoras, and which he says he has used with 
great satisfaction to himself, and with the best success, and he recom- 
mends its temperature to be from 75° to S5°. 

In more severe cases, however, venesection may be required, but 
should never be adopted upon slight grounds, even if the patient be 
plethoric. The circumstances which serve to render general bleed- 
ing necessary, are, symptoms threatening an apoplectic attack, or 
showing the existence of inflammation in some internal organ; and, 
as Dr. Scudamore justly remarks, <« in the circumstances in which 
bleeding is a proper remedy, its early employment is a point of 
much importance. When delayed, it will be found that the depres- 
sion of strength resulting from the excessive irritation of the nervous 
system counteracts its advantages in a great degree." The pulse, in 
some measure, affords a guide; if it be full and hard, accompanied 
with a hot skin, thirst, and scanty high-coloured urine, general bleed- 
ing can rarely do harm, and is absolutely necessary if inflammation 
of any internal organ exist. The quantity of blood which ought to 
be abstracted is regulated by circumstances that have been already 
fully considered when treating of many other diseases ; but so cau- 
tious should we be about opening a vein, that I would strongly 
recommend, in the first instance, the application of a considerable 
number of leeches to the affected part, particularly if much local 



GOUT. 833 

inflammation exist. This practice is recommended because it seems 
to be following the course pointed out by nature. In determining 
the number of leeches that may be necessary, it is much safer to err 
by applying two or three too many, than too few, because, if a suf- 
ficient quantity of blood be not drawn, the advantages from the 
depletion are counterbalanced by the additional irritation from the 
bites. But we must always keep in view, in the treatment of gout, 
that the disease is produced by constitutional causes, and is not to be 
altogether relieved by local means. The practice of leeching the 
part affected is noticed by Cullen,and has, in some measure, received, 
his sanction, although, it would seem, he had not often employed it. 
In par. 563, he says: "I believe, however, that bleeding by leeches 
upon the foot and upon the inflamed part, may be practised and 
repeated with greater safety (than general bleeding ;) and I have 
known instauces of its having been practised with safety to mode- 
rate and shorten paroxysms; but how far it may be carried, we have 
not had experience to determine." 

Emetics have been extolled by some, but are only to be adminis- 
tered if indigestible food is suspected to be lodged in the stomach, 
and when there is distressing irritation from slight nausea, and hot 
acid eructations. 

Mercurial preparations are to be occasionally given in conjunction 
with laxative medicines, particularly if the stools show either a de- 
ficiency of bile, or are dark-coloured and fetid. It is immaterial 
whether we use calomel or the blue pill; sometimes, indeed, when 
the liver seems implicated, a slight mercurial course is necessary. 

In cases where there is a burning heat at the pit of the stomach or 
other signs indicating inflammation, or even a high degree of irrita- 
tion of the mucous membrane of the stomach and bowels, a sufficient 
number of leeches must be applied, or cupping had recourse to, 
followed by rubefacients or blisters. I have often seen considera- 
ble benefit in cases which indicated, not only the existence of ab- 
dominal, but also of thoracic disease, by producing two or three 
successive crops of eruptions, by means of the tartar-emetic oint- 
ment. 

Opiates are highly serviceable in allaying pain and producing sleep, 
and have been ill greater favour with practitioners than any other 
oi remedies; hut they are inadmissible before the bowels have 
been sufficiently relieved — when the patient is threatened with apo- 
plexy, or any other cerebral affection — and, indeed, when there is 
local inflammation of any internal organ, unless they be conjoined 
with the remedies necessary for its cure. When opium disagrees, 
hyoscyamus may be substituted. 

Many years have not elapsed since the cau medicinale was in high 
repute, but it baa now shared the fate Of the Portland powder and of 

all other pretended specifics for gout. 

The eotchicum autumnal* has been highly recommended during 
paroxysms of gout, and has been used with tin; best effects, not only 
in alleviating the immediate Bufferings of the patient, but in breaking 
the severity of the disease; hut it has no claim to the title of a spe- 
cific. There is considerable diilereuce of opinion among practical 
70 



834 GOUT. 

men as to which preparation of colchicum is the most efficacious. Some 
recommend the powder of the bulb; others that of the seed; many 
prefer the wine of the seed ; while others extol the acetic preparation. 
I have used all the preparations, but find a saturated infusion of the 
seeds in wine to answer better than any other. It is to be exhibited, 
according to the age and constitution, in doses from twenty to a hun- 
dred and twenty drops, conjoined either with the same quantity of 
tincture of hyoscyamus, or with a half, or even a third part of the 
sedative solution of opium, which will be found to answer better 
than laudanum. In some cases, when the stomach is exceedingly 
irritable and when the colchicum cannot be retained, leeches may be 
applied, or a blister over the epigastric region, and a pill with two, 
three or four grains of calomel and two of opium, may be exhibited. 
In treating a case of the gout with colchicum, it is by no means to be 
trusted to alone, as if it were a specific ; it is necessary to attend to 
the state of the bowels, and allay local inflammation in the same 
manner as if colchicum were not employed. 

Alkalies are very serviceable when there is acidity in the stomach, 
or when there is much irritation in the urinary organs, particularly 
when the urine is high-coloured, and deposits a red, sandy sediment. 
If it be necessary, at the same time, to give any laxative medicine, we 
may use Henry's calcined magnesia, in which are conjoined antacid 
as well as aperient properties. 

During paroxysms of those forms of gout which have been termed 
"atonic" and "retrocedent," we must treat each case according, not 
only to the organ affected, but to the nature or kind of the affection. 
We must be careful not to confound mere functional disorder with 
inflammation, an error which young practitioners are very liable to 
commit, but which is not attended with fatal consequences nearly so 
often as mistaking inflammation for the other class of affections. 

In cases where pain and inflammation are shifting about from 
place to place, it is a good plan to leech such parts, as well as to pro- 
duce contra-irritation on the chest if respiration be at all affected or 
the patient troubled with palpitations: and on the epigastric region, 
if there be evidence of much gastro-intestinal irritation. Should 
inflammation attack any organ, it must be treated upon general prin- 
ciples, always, if possible, making use of leeches or applying cupping- 
glasses instead of venesection, unless the patient be young and ple- 
thoric, or there be signs of local congestions or unusual determinations 
of blood to any particular organ. 

Management of Gouty Subjects during the Intervals. 

As soon as a gouty paroxysm begins to subside, it is our duty to 
make the patient aware of the usual progress of gout in undermining 
the constitution, in order that he may the more readily submit to 
directions which he is to receive for his future management. It ought 
to be impressed upon him that medicines can be of little comparative 
service, unless he live abstemiously and alter many of his habits. 
Perhaps the point of most importance is a proper regulation of the 
diet, so as to make it correspond to the degree of his daily exercise. 



GOUT. 835 

I am aware how impossible it is to prescribe a proper diet for each 
individual, until we come to know his peculiarities of constitution 
and previous habits, but there are certain general directions which it 
is advisable to give in all cases, in the first instance, at least, which 
can be modified and changed afterwards according to circumstances. 
At breakfast the patient may be allowed one large breakfast-cup 
of milk, tea, coffee or chocolate, according to his taste, with an egg 
and bread and butter. Meat and fish should be interdicted at this 
meal, which should be taken at eight o'clock in the morning, to 
ensure his rising early; as well as for the purpose of regulating the 
hours for the other meals. From that time he should take nothing 
till dinner, which should be about two o'clock; when he may be 
allowed a moderate quantity of animal food, not exceeding from a 
quarter to half a pound, cooked in a plain way, perhaps on a gridiron 
is the best, with as much stale bread as he chooses, and a small quan- 
tity of any of the ordinary vegetables that agree with him; but he 
must dine upon one dish, particularly for some time after a paroxysm. 
At any subsequent period, should he wish to partake of two articles 
at one meal, the quantity of each must be regulated in such a man- 
ner that the stomach is never over-distended. Should he take fish, 
it must be eaten without melted butter, a good substitute for which 
is meat gravy; and the reason why vegetables should be avoided as 
much as possible, is that they tend to produce acidity and flatulency 
in the stomach and bowels, when their functions are in a weakened 
state. For drink, I believe that good, sound table-beer will be found 
to agree very well with the generality of people, if it be not hard or 
too weak, and if it be taken in moderate quantity. If beer should 
disagree, a dessert-spoonful of brandy in a tumbler of water will be 
found a very good substitute. With respect to wine, the use of it 
depends entirely upon former habits; were old gourmands deprived 
altogether of their usual stimulus they would quickly sink; but in 
younger subjects, when the constitution is as yet unbroken, it will be 
well to advise the patient to avoid the habitual use of any stimulant 
whatever. At 7 o'clock in the evening, the patient should have an- 
other meal, consisting of the same articles as at breakfast; and if he 
take any i!nn_' afterwards, which I do not, however, think necessary, 
n may be a teacnpful of gruel al ten o'clock, on retiring to rest. 

lb ihould sleep in a large, well-aired room, with sufficient clothing 
to make him feel comfortable, but not to produce perspiration, the 
continuance of which tends to occasion constitutional debility, per- 
haps more than any other eiiviunstance whatever. It should be as- 
certained, when the patient goes to bed, that his feet are comfortably 
warm ; if not, friction should be used, or he should be supplied with 
a bottle of hot water ; whereas, if they should be too hot, which is 

sometimes the case, they should be bathed for some minutes in milk- 
warm water. A L'oiily person, in particular, should not sleep on a 

feather bed, not should he indulge in the use of soft pillows, more 

•i ally if there be any tendency of blood to the head, when ins 

head and shoulders ought t<> be considerably elevated. The bowels 

should form a chief object "I" attention ■ they must not be allowed to 

be constipated; but the opposite extreme is fully, if not more inju- 



836 GOUT. 

rious. Many individuals are injured by the pernicious habit of 
taking some strong physic now and then; but it will be invariably 
observed that the bowels become afterwards more torpid. All lax- 
ative medicines, which operate violently or produce watery stools, 
should be avoided. Patients should be furnished with different kinds 
of pills, of which they should regularly take such a quantity as will 
produce one, or at most two evacuations daily, or a teaspoonful or 
two of Henry's calcined magnesia, sometimes by itself, at others 
joined with six grains of rhubarb and three or four of ginger. 

During the day care must be taken to preserve the feet in a pro- 
per degree of warmth ; and the patient should at first be very cau- 
tious not to use too much exercise, which will not only weaken the 
body and derange the functions of the stomach, but will injure the 
limb which has been recently the seat of inflammation. By degrees 
the exercise maybe increased, but should never be violent or carried 
to such an extent as to create fatigue. Till his health is completely 
established he should avoid exposure to night air, and at all times 
carefully protect his body against the influence of atmospheric vicissi- 
tudes. 

At any period that digestion becomes impaired, which will be 
indicated by a loaded tongue and a sense of fulness and distension 
after meals, patients should not depend so much on drugs for relief 
as on the restrictions of diet, but I do not mean to undervalue the 
effects of medicines. Every practical man must be aware how ad- 
vantageous are a blue pill or a grain or two of calomel and a small 
quantity of extract of colocynth when the tongue is loaded with a 
white or with a yellowish fur. These, with the addition of from ten 
to twenty drops of nitric acid in four ounces of infusion of quassia, 
compound infusion of gentian, or in water along with two grains of 
the sulphate of quinine, once, twice or thrice a-day, are often bene- 
ficial. In some constitutions the occasional use of the warm bath 
will be found serviceable, while in others the cold bath will best 
agree. There is almost no individual so situated that he cannot ob- 
tain the advantages frequently found to result from the shower-bath, 
which may at first be used warm, and afterwards gradually made 
more and more cold as the strength increases. 



CHAPTER II. 
RHEUMATISM. 



Most authors describe two, others three varieties of rheumatism, 
viz.: the acute and chronic rheumatism and rheumatic gout, which 
last is so termed from its resemblance to both diseases. The follow- 
ing is Dr. Cullen's definition of acute rheumatism: — "A disease 
produced by an external cause which is, in general, known, attend- 
ed with pyrexia; pain about the joints, following the tract of the 
muscles, attacking the knees and larger joints in preference to those 
of the feet or hands, increased by external heat." 

Dr. Mason Good has given the following definition: " Pain, in- 
flammation and fulness, usually about the larger joints and sur- 
rounding muscles; often wandering; urine depositing a lateritious 
sediment; fever a cauma" (inflammatory). 



ACUTE RHEUMATISM. 

Although the diseases cannot certainly be identified, yet there 
are many strong points of analogy between gout and rheumatism. 
Few men can be long in practice without meeting with cases which 
have some resemblance to gout, and some to acute rheumatism, so 
much bo, that it is a common enough circumstance to hear practical 
men speak of" rheumatic gout." Some, indeed, maintain thai gout 
and rheumatism are only varieties of the saint: disease; while others 
allege that, although they are not exactly the same, yet the one often 
passes into the other. 

Acute rheumatism generally attacks young people, or those rather 
below than above middle age, after long exposure to cold and mois- 
ture, as Bleeping in damp sheets, remaining long in wet clothes, par- 
ticularly after fatigue, or from changing winter clothing too early in 
spring, to which people are often tempted by a lew successive days 
Of Warm weather. 

Symptoms of untie rheumatism. — Alter exposure to some of the 
above-mentioned causes, the patient complains of rigors or chilliness, 

with a general feeling of numbness, pain or aching: febrile symptoms 
toon follow, when the skm is pungently hot and the pulse quickj full, 

hard and bounding, even m weakly subjects, and will be found to 

beat from 100 to 1 to, perhaps even higher. As the febrile symp- 
toms increase, the pam becomes more acute; it is generally an aching 

70* 



838 RHEUMATISM. 

or gnawing pain, with numbness and powerlessness, and it some- 
times even possesses the pungent, hot, lancinating character of gout. 
The pain is sometimes general, but some one joint is more intensely 
affected than the rest; and we also see translations of the disease 
take place, which are so frequently observed in gout. In acute 
rheumatism, the parts affected usually become red, swollen and 
tender to the touch, although in some cases it is observed that the 
redness and swelling are slight in comparison to the degree of pain. 
The least motion aggravates the pain, as in gout, and it often shoots 
with great severity, either along the course of the muscles or the 
nerves and their ramifications. 

Sometimes local pain exists before the general febrile commotion, 
although this is rare, unless a patient with chronic rheumatism, from 
imprudent exposure or other causes, excites the acute form of the 
disease. The pain and febrile symptoms abate and increase irregu- 
larly ; generally speaking, however, the patient is most tormented 
at night, which circumstance is observed in almost all other diseases. 
The muscles often feel hard, rigidly contracted and sore to the touch; 
the intercostals are occasionally affected in such a manner as to re- 
semble in every respect an attack of pleurisy, which has been already 
noticed, when treating of that disease, under the term " Pleurodinia." 
The muscles of the abdomen are occasionally painful to the touch, 
without hardness of the part, so as to resemble peritonitis. The 
muscles of the back are often affected, the complaint being well 
known by the term " lumbago." Another affection, either of the 
sciatic nerve or of the muscles which pass from the trunk to the 
lower extremities, sometimes takes place, which is called " sciatica." 
These latter affections, however, very frequently occur without fever, 
unless during the night, and are usually described under the head of 
chronic rheumatism. 

In acute rheumatism the tongue is generally loaded, often red, 
particularly round the edges, and fissured; the appetite is destroyed; 
the thirst excessive ; the urine scanty and high-coloured, depositing 
a heavy sediment, as in gout. There are sometimes nausea and 
vomiting, with considerable internal heat, particularly in the epi- 
gastric region, with irregular, generally costive bowels and fetid 
evacuations. At others there are headache, with intolerance of 
light, and sometimes even inflammation of the eyes, which is well 
known to attack a particular part, viz. the sclerotic coat. On other 
occasions, symptoms of cerebral irritation or inflammation take place; 
and it is well known that dissection has frequently and unequivocally 
revealed an inflammatory condition of the membranes of the brain. 
But the pericardium of all parts is the most liable to the occurrence 
of inflammation during the course of rheumatic affections— a most 
insidious disease, under any circumstances, but more particularly so 
when the attention of both patient and practitioner is attracted to 
the pained joints. The skin is generally dry and hot in acute rheu- 
matism, but is sometimes bathed in a clammy sweat. 

In the consideration of all diseases, after becoming acquainted with 
their phenomena, the most important point is to determine their na- 
ture and seat. With respect to acute rheumatism, some allege that 



RHEUMATISM. 



839 



it is a disease of the sanguiferous, others of the nervous system. My 
own opinion is, that both systems are deeply implicated, but that the 
real nature of the disease is inflammatory. All the symptoms prove 
this position, for even in the weakest subject the pulse is quick and 
strong ; the fever is undoubtedly inflammatory; the affected part 
generally possesses all the characters of inflammation ; and blood, 
when drawn from a vein, shows an inflammatory crust. 

It would be interesting if we knew whether the inflammation 
were situated in the cellular substance, in the muscles, nerves, blood- 
vessels or lymphatics. That the inflammation is not seated in the 
cellular substance is rendered probable from its rarely terminating 
in suppuration, ulceration or gangrene. I cannot pretend to deter- 
mine the seat of the inflammation; but from the quick translations 
which take place and the resemblance which rheumatism in many 
points bears to gout, it is very probable that it involves the nervous 
filaments more considerably than any other tissue. But I have seen 
cases which presented symptoms similar to those of rheumatism, in 
which, after death, the lymphatics of the limb were found inflamed 
and filled with a puriform fluid. Many French pathologists have 
come to the conclusion that rheumatism is nothing more than acute 
inflammation of the lining membrane of the arteries. 

Treatment of acute rheumatism. — Many writers insist much 
upon the importance of a proper diagnosis between gout and rheu- 
matism ; but practical men know how difficult this is in many cases, 
how impossible in some, and I might add unprofitable in many, as 
both diseases must be treated very much upon the same principles, 
with this exception, that rheumatic subjects bear bleeding better than 
gouty, and that in them it is generally more beneficial. 

The following diagnosis has been drawn between the two diseases: 



Gout is a disease which rarely attacks 
iquently 
. .: males. 

Gout is more connected with - 

ticularly with 
d with 

ion. 



Gout generally infests the smaller 

i', the pain is burning, pungent 
.i n 1 1 lancinating. 

i rat, the external Inflammation is a 
bright, Intense red: the iwellln • 

rapidly tad I ■ b more 

■ and tender. 



Acute RkeumatUm. 

The young are as liable to this disease, 
if exposed in its causes, as those more 
advanced in age, and females as well as 

Rheumatism frequently attacks peo- 
ple in perfect health, and is always to 
i to cold and moisture, although 
acute inflammation of an internal organ 
may be produced at the same time with 
■iiial disease, or may be subse- 
quently engrafted on it by translation or 
other* i 
Rheumatism attacks the larger joints. 

The pain is generally gnawing and 
numb, occasionally pungent and Lancina- 
ting. 

in rheumatism, the Inflammation is said 
d e, and the swelling not so 
great or, at least, so rapid, h 
also that rheumatism shows more regular 
exacerbations towards night than 

and that the pulse is mere- lull. 08 

wi -, which characters li often pre- 
Ibi a considerable period after the 

subsidence of the external Inflammation. 



840 RHEUMATISM. 

A great deal of discussion has taken place in the profession re- 
specting the treatment of rheumatism. One set of practitioners 
depend entirely upon venesection : another upon purging ; a third 
upon exciting long-continued profuse perspirations; a fourth upon 
the exhibition of bark alone ; and a fifth upon a course of mercury 
to produce salivation. It is no wonder, therefore, under such empiri- 
cal treatment, that an attack of the disease used formerly to continue 
violent for such a long period of time. Formerly an attack of acute 
rheumatism, with its sequelae, generally confined the patient for 
twelve months, that is to say, before he regained his ordinary state 
of health, and few got off with less than six months' confinement to 
bed. Of late years, more common sense pervades the profession, 
and each case is now treated more upon pathological principles. The 
best remedy we possess for the cure of acute rheumatism, is vene- 
section, provided the patient be plethoric or have an unbroken con- 
stitution, and the disease be in its early stages. The general inflam- 
matory diathesis which prevails, the local inflammation in the parts, 
the highly inflammatory state of the blood and the knowledge which 
we have derived from post mortem examinations — all proclaim the 
propriety of general bleeding, in severe cases, in the circumstances 
already mentioned. The precise quantity of blood to be taken, can 
only be determined by watching its effects upon the constitution. 
We frequently, however, meet with people of nervous, irritable ha- 
bits of body, and others who have been much injured by dissipation, 
in whom venesection will, in general, prove injurious ; and I may 
add that it will often produce bad effects even in the strongest con- 
stitutions, unless it be followed up by proper after treatment. 

The good effects of the tartrate of antimony in small but frequently 
repeated doses, so as to keep up slight nausea without producing 
vomiting, cannot be praised too highly; but the patient should be 
lightly covered with bed-clothes, so as not to excite perspiration. 
I have often employed antimony with great success in cases where 
general bleeding was inadmissible; but if there be considerable 
plethora, and a strong, hard, bounding pulse, antimony will have a 
better effect when venesection is premised. 

Local bleeding by leeches has very good effects, and ought never 
to be neglected when the inflammation runs high. When leeches 
are employed, however, a considerable number should be used; and 
I make it a rule, after the leeching is commenced, to chase the dis- 
ease, as it were, from joint to joint without intermission, pursuing 
other means of treatment at the same time. 

In many cases, decided and immediate advantage will be derived 
from the employment of colchicum, combined with the sedative 
solution of opium, or with large doses of the tincture of hyoscyamus, 
precisely in the same manner as has been recommended in gout. It 
sometimes succeeds after the failure of antimony ; but in general I 
like to try the latter before having recourse to the colchicum. 

It is highly necessary, throughout the whole course of the disease, 
to keep the bowels moderately open ; but violent purging is by no 
means necessary, and is often injurious. If the tongue should be 
loaded with a white or yellow crust, two or three grains of calomel, 



RHEUMATISM. 841 

combined with four or six of rhubarb, or four grains of colocynth, 
may be given at bed-time, and the operation assisted next morning 
by castor oil or an injection. 

The old plan of sweating patients for ten or fourteen days, by 
means of large and repeated doses of Dover's powder, warm di- 
luents, and a load of bed-clothes, is, I hope, now very generally 
abandoned, as it is attended with the same injurious effects as too 
frequently repeated and indiscriminate bleedings. 

I can say nothing, except in condemnation, of another plan'too 
indiscriminately followed, viz., the calomel and opium treatment. I 
have often seen the tongues of patients swollen and ulcerated, and 
profuse salivation produced without the least sign of amendment. 

The Peruvian bark was formerly highly extolled in acute rheu- 
matism, and has been used and approved of by many celebrated 
physicians of the last a^e. Dr. Ilaygarth came to the conclusion 
that "bark does not cure an ague so certainly and so quickly as it 
does the acute rheumatism.'' It is impossible to reconcile such a 
statement with the opinions maintained by others respecting the 
same medicine. "The Peruvian bark (says Cullen, par. 469) has 
been supposed a remedy in some cases of this disease; but we have 
seldom found it useful, and in some cases hurtful." I formerly tried 
bark in all its forms, and my experience exactly corresponds with 
that of Dr. Cullen; in fact, I have never seen it useful, except in 
one case, when it was employed after copious venesection. There 
can be no doubt, however, that cases may occur in which the sul- 
phate of quinine will be found beneficial, where the bark in sub- 
stance would prove injurious, and the infusion, or any other pre- 
paration, too weak to have any effect whatever; and there is much 
good sense and discrimination in the following passage from Cullen. 
Speaking of bark, he says, — u It appears to me to be fit in those cases 
only in which the phlogistic diathesis is already much abated, and 
where, at the same time, the exacerbations of the disease are mani- 
festly periodical, with considerable remissions interposed." 

With regard to stimulants, such as gin and brandy punch, and a 

bottle or two of poi t-wine daily, which are so generally prescribed by 

ie, I shall say nothing. It is to be regretted that the laws appli- 

ii men in China cannot be IkuI recourse to in this 

country.* 

B sn ought never to be employed iti acute rheumatism, at least 
in the early Stages, unless there be evidence of the existence of peri- 
carditis, ot inflammation of some other internal organ. 

Fomentations are seldom serviceable, and tin; warm bath is often 
injurious in acute rheumatism, from the increased pain produced by 
the motion which it requires. The sulphurous vapour bath, how- 
r, has been much praised byseveral individuals, but in looking 
at a table of M. Gale, 1 find nothing to recommend it. The plan 
was tried in sixty-fivi whicn twenty-five only were cured, 

thirty-two were stated to have been much relieved, and eight derived 

no benefit from the remedy. 

Pens] Code of China, by Sir George ThMnia BtaxmUm, 181 



842 RHEUMATISM. 

The diet should be antiphologistic during the acute stage, and 
farinaceous and unstimulating for some time after, until the pulse 
ceases to be full and bounding. After the patient has been for some 
time convalescent, when the limbs are stiff, and the joints somewhat 
rigid, good effects will be occasionally produced by general cold 
bathing; but the health and strength must be in other respects quite 
restored, and all the functions natural. Frictions with a hair glove 
are to be used and persevered in. 



CHRONIC RHEUMATISM. 

This form of rheumatism sometimes succeeds the acute disease 
and may be confined to one part of the body, or may be general. The 
patient complains of a dull, gnawing pain, increased on motion, with 
little or no fever or local inflammation. There is frequently swelling 
about the joints and occasionally contraction, and the muscles are 
sometimes rigid. The pains are often relieved by the application of 
heat, but are always aggravated by exposure to cold, damp air, and 
occasionally also by the application of heat, so that frequently pa- 
tients pass painful and restless nights. 

In this form of the disease, the warm water and the vapour bath, 
together with rubefacients are found more beneficial than in acute 
rheumatism. The Russian plan of treatment is said to be decidedly 
superior to any other, which is to expose the patient to vapour at a 
very high temperature, in a room where the evaporation of water is 
produced by dashing it upon stones intensely heated. After this has 
been persevered in for some time, the patient still remaining in the 
same apartment, small quantities of cold water are dashed upon the 
parts affected; the body is afterwards well rubbed. I am told by a 
gentleman who has undergone the process, that the relief is very 
decided. 

If there be any fever, the antimonial treatment will be found 
beneficial, as well as colchicum ; and, in several cases, I have seen 
permanent advantage produced by the combined effects of the wine 
of colchicum and tincture of hyoscyamus. 

It has been already mentioned, that rubefacients are sometimes 
serviceable, and it may be now stated, that excellent effects have 
been occasionally observed to follow the application of blisters, but 
more particularly the contra-irritation produced by antimonial oint- 
ment and moxas, a remedy in great repute on the continent. 

Train oil, obtained from the liver of the codfish, is highly extolled 
by Dr. Percival, and has since been used by other individuals, particu- 
larly by Dr. Bardsley, who exhibited from one to three tablespoonfuls 
daily. I have seen it tried, and persevered in for some weeks at a 
time, without observing any benefit whatever from its use; and I 
can only wish a few doses were exhibited to those gentlemen who 
have the patience to prescribe it for others. 

The arsenical solution and bark have been recommended, when 
the disease shows any tendency to periodicity. 

Of late years acupuncturation, which is said to be an eastern 



RHEUMATISM. 843 

remedy for this disease, has been employed in various parts of Eu- 
rope for the cure of chronic rheumatism, and with most astonishing 
good effect; the operation is said to produce little or no pain, and no 
haemorrhage. A single puncture has been found sufficient to remove 
an ache of some years duration; generally from two to six sharp- 
pointed needles are used at once, and are pushed, at a little distance 
from each other, into the affected part to the depth of half an inch, 
and in fleshy parts, even of an inch; each needle is allowed to remain 
for about five minutes before it is withdrawn. It is observed that the 
pain sometimes leaves the part into which the needles have been 
introduced and flies to another; but we are told to follow it with the 
instrument. 

Lumbago and sciatica appear to me to be more decidedly of a 
nervous nature than any other, and are to be treated in the follow- 
ing manner: — viz., by gentle laxatives, frictions and rubefacients, 
and the frequent use of the hip-bath. But what answers fully better, 
is to pour a small stream of very hot water over the part affected, 
the patient being placed in a comfortable posture, either sitting on a 
bidet, or any convenient article to receive the water, which should 
be heated to 130° or 140°. In fact, it should be so hot that the 
finger cannot be kept immersed for any time. Acupuncturation may 
also be necessary in sciatica, which is the most intractable of the two 
affections, although commonly not so severe. I have seen the best 
effects produced, even in old-standing cases, by wearing a chamois- 
leather jacket and drawers in all the forms of chronic rheumatism. 
It is of the utmost consequence to regulate the diet, as relapses may 
be frequently traced to indigestible articles of food. It is said that 
individuals previously liable to attacks of lumbago and sciatica, have 
jied further annoyance by wearing a piece of stick-sulphur in 
their breeches pockets; and it is well known that the internal use of 
sulphur is a popular remedy for all forms of rheumatic complaints. 



RHEUMATIC GOUT. 

I do not consider it necessary to give a description cither of the 
phenomena of this disease or its treatment, as it is sufficient for all 
practical purposes to refer to what has been already said respecting 
gout and rheumatism. 



CHAPTER III. 
SCROFULA. 



Dr. Cullen has given the following definition of scrofula : — 
"Enlargement of the conglobate glands, especially in the neck; the 
upper lip and columnae nasi and lower part of the nostrils tumid; 
the face florid; the skin soft; the abdomen enlarged." 

Dr. Mason Good, who applies the term " struma" to this class of 
affections, gives the following definition :— " Indolent, glandular 
tumours, chiefly in the neck; suppurating slowly and imperfectly 
and healing with difficulty; upper lip thickened; skin smooth ; coun- 
tenance usually florid." 

The belief is almost universal that this class of diseases is here- 
ditary, and that it is confined to an unhappy few, who transmit it 
from father to son, from one generation to another, far more regu- 
larly than they transmit their money or virtuous reputation. I must 
confess my scepticism upon this point, as many instances might be 
quoted where both parents were strongly marked with all the appear- 
ances described as scrofulous, nevertheless their children were very 
healthy. On the other hand, cases are often seen where the parents 
had no vestige of the complaint, and yet the children were scarcely 
ever without some of the affections generally denominated scrofu- 
lous. Many authors, aware of these circumstances, observe that it 
is true the parties are not born with the disease, but only with a 
greater aptitude to receive certain morbid impressions, which may 
bring the latent disposition into action. This is a very plausible 
salvo, but it is too vague to be received as medical evidence. They 
also say, that a remarkable circumstance attending scrofula is, that it 
does occasionally pass over one generation, and appear again in the 
next, so that " the grandfather and grandson shall be both scrofu- 
lous, while the intermediate person, who holds the most intimate 
relation of father and son, and connects the two others, shall be ex- 
empt from any attack of the disease. 

My opinion with respect to glandular affections denominated scrofu- 
lous, is, that they are generally engrafted on the constitution by im- 
proper food and deficient clothing ; — by neglect or bad medical 
treatment during the period of dentition ; the progress of scarlet fever, 
measles and other eruptive fevers, as well as during the ordinary 
eruptions and affections of the throat. And lastly, that they are pro- 
duced by mismanaging swollen and inflamed glands during their 
early stages. Hence it is a disease with which some of the members 



SCROFULA. 845 

of almost every family in this climate are at one time or another 
affected. We see glandular affections in persons of every variety 
of colour of the hair, eyes and appearance of the skin, and in every 
variety of constitution. I have, therefore, long ago persuaded my- 
self that they depend upon gastro-intestinal irritation, which point 
of pathology has been clearly established with reference to the most 
scrofulous of all scrofulous diseases, viz., that which is termed " tabes 
mesenterica" This view is much strengthened by the following 
circumstances: — Scrofula is a frequent disease among the poor, and 
those who are fed upon large quantities of weak broth, coarse, ill- 
baked bread, or hard, indigestible puddings. From these causes the 
disease is often seen in charitable establishments for children; and I 
have also seeu it traced to English boarding-houses, where the 
children are crammed with hard pudding before they are allowed 
even to smell meat, and are told " that the young ladies and gen- 
tlemen that eat most pudding shall have most meat" — Poor 
children! Another important fact may be mentioned, that scrofulous 
affections can be produced in a short space of time in many of the 
domestic animals, by unwholesome feeding. Thus I have seen them 
purposely produced in poultry, rabbits and pigs, by such means. A 
pig is called " measly " when it is affected with a very general 
disease of the glands throughout the body, which is well known to 
depend upon the manner in which it has been fed. 

It has been my belief, for many years, that many of the affections 
called scrofulous, may, in a considerable number of instances, be 
traced to the exanthemata. In order to obtain precise facts upon the 
subject, I requested Dr. Robertson, Surgeon to the Edinburgh Eye- 
Dispensary, to preserve a list of all diseases of the eye usually de- 
nominated scrofulous, as well as those accompanied by glandular and 
cutaneous affections, usually attributed to scrofulous action, in order 
to ascertain how many were attributed by the parties themselves or 
their parents to the exanthemata and hooping-cough. Dr. Robertson 
accordingly directed his attention to this point, and, in the course of 
twelve months, informed me that almost all the cases were attributed 
by the parties themselves, or their friends, to those diseases. This 
investigation took place nine yean ago; and Dr. Robertson informs 
me that he has seen nothing in his extensive experience, since that 
period, to weaken the effect which it made upon his mind. It may 
be added, that the result of my daily practice confirms and supports 
the views already stated. 

There seems good ground for the following statement, made by 
Mr. Lloyd, in his valuable Treatise on Scrofula, p. 7.: — "Among the 
symptoms indicating a disposition to scrofula, it has been already 
observed ihat a lair complexion and light hair and eyes are gen. - 
rally mentioned \ but I believe there are. no legitimate grounds for 
such distinction. Indeed, I am fully convinced, from a very extent 
sive investigation of the subject, thai persons of every variety of com- 
plexion are alike subject to (Ins disease ; and that it is only necessary 
to place them in eiroumstanCOS favourable for Us development, to have 
it fully established." 

The reasons will now appear evident why scrofula is a disease that 
71 



846 SCROFULA. 

no one can properly define; every physician having a definition of 
his own. The term is applied too often to diseased states of the 
system, with the nature of which the physician is entirely unac- 
quainted; and it is too frequently used for the purpose of concealing 
professional ignorance, when he is puzzled and foiled in the treat- 
ment of disease. 

I most heartily coincide with the sentiments expressed by Mr. 
Lloyd in the following paragraph: "In describing the symptoms 
indicating a scrofulous diathesis, all the authors with whom 1 am 
acquainted have fallen into the error of describing the state of a 
patient, after the disease has given local evidence of its existence, 
instead of informing us of the temperament or habit of body of the 
patient antecedent to this period; a circumstance which I cannot but 
consider as of the highest importance in our pathological research. 
Thus they enumerate among the symptoms of a scrofulous diathesis, 
or which only denote a tendency to scrofula, ' a thickened, chapped 
upper lip, the thickening extending to the alse of the nose/ * tume- 
scence and redness of the tarsi,' with weakness of the eyes in general, 
'tumid belly' and 'enlargement of the lymphatic glands, particularly 
those of the neck.' These, it is true, (continues he,) afford very 
decisive evidence of the existence of the disease, but should not be 
ranked among the symptoms indicating only a disposition to it. All 
the other symptoms illustrative of the same point, which have been 
adduced, are either dubious or uncertain; as fair and shining skin ; 
light hair and eyes, females being more subject to it than males, or 
males, than females; both of these contradictory positions having 
their respective advocates." (Page 3.) 

I have many cases annually under my care illustrative of these 
statements, and proved not only by the previous history, but by the 
effects of proper remedies. For, as the functions of the stomach and 
bowels become more impaired, the inflamed and tumid appearance 
of the eyes, nose or lip become more and more evident, until, per- 
haps, ulceration takes place. But as the condition of these functions 
is improved, the above described state of parts disappears. 

All parts of the body are liable to be affected by scrofulous degene- 
ration ; thus it is seen in the brain, lungs, heart, liver, spleen, kidneys, 
muscles and bones, and also in serous and mucous membranes. 

I cannot do better than extract the following description of scro- 
fula, when left to itself, from Dr. Cullen's " First Lines on the 
Practice of Physic," (par. 1743, et seq.) "Frequently the first 
appearance of the disease is the tumid and chapped lip above men- 
tioned. Upon these occasions, the first appearance is that of small, 
spherical or oval tumours, movable under the skin. They are soft, 
but with some elasticity. They are without pain and without any 
change in the colour of the skin. In this state they often continue 
for a time, even for a year or two, and sometimes longer. Most 
commonly they first appear upon the sides of the neck below the 
ears, but sometimes also under the chin. In either case, they are 
supposed to affect in these places the conglobate or lymphatic glands 
only ; and not at all the salivary glands, till the disease is very 
greatly advanced. The disease frequently affects, and even at first 



DROPSY. 857 

doubt produce general debility, and likewise dropsy, in consequence 
of the diseased conditions of the stomach, liver or kidneys, which 
they occasion. 

Dr. Cullen also considers that dropsy may be produced by a pre- 
ternatural abundance of serum in the blood-vessels, which may be 
sometimes owing to drinking a large quantity of very cold water, or to 
absorption from a moist atmosphere, or to a fault in the digestive and 
assimilating powers in the stomach and other organs. Besides these, 
he mentions other causes which are more likely to produce inflam- 
mation than dropsy— as the rupture of the thoracic duct, and a con- 
sequent effusion of chyle and lymph into the thorax; and a rupture 
or erosion of the kidneys, ureters and bladder of urine — " whereby 
the urine has been poured into the cavity of the abdomen, and pro- 
duced an ascites." (Par. 1661.) 

From these theories I turn with pleasure to the pathological work 
of Dr. Blackall, and the still more useful and splendid production of 
Dr. Richard Bright, of London. 

Dr. Blackall seems to have been the first author who drew the 
attention of the profession in a particular manner to the coagulable 
state of the urine, and to the prevalence of an inflammatory diathesis 
in some kinds of dropsy. He proved by dissection that the pleura, 
the peritoneum and pericardium are often unequivocally inflamed, 
covered with false membrane, and adhering to adjacent parts; — that 
the liver and kidneys are frequently enlarged and otherwise diseased; 
— that the lungs sometimes show marks of inflammation ; — that the 
lymphatic vessels themselves are found unusually thickened and dis- 
tended in dropsical bodies, so much so, that he alleges such subjects 
are much preferred for anatomical preparations ;— and, lastly, that the 
cellular membrane, in dropsical parts, frequently presents an unusual 
resistance to the knife, and that the cells contain an effusion some- 
what transparent and coagulated, 

Dr. Blackall thinks that the inflammatory nature of dropsy is so 
far made out by the following facts: 

" 1. The serum of the affected cavities has been often found 
opaque in various degrees, discoloured and containing pieces of 
lymph | and in one instance, even the fluid of the cellular membrane 
coagulated spontaneously. 

"2. In addition to these appearances of the dropsical fluid, which 
argue a secretion often different from that of mere relaxation, the 
membranes likewise are sometimes greatly inflamed and disfigured. 

"3. Many of the remedies are antiphlogistic; and there is a cer- 
tain stage in almost every case of the disease, in which tonics do 
material injury. 

'■ 1. The frequent hufliuess of the blood, and that, too, sometimes 
of a peculiar kind, is not to be overlooked in this investigation ; and 
it is worthy of iiiiuli notice, that whilst the blood and the secreted 
serum ire accused of being lOO watery, the urine, which commonly 
contains little or no alhunieii, is loaded with it in a meat and un- 
natural proportion. This phenomenon could hardly be expected 
as the result of too thin a condition of the thuds, and a deficiency of 
coagulable matter; on the contrary, it is a very strong proof, it not 
72 



848 SCROFULA. 

imbued with a peculiar sharp acrimony, and therefore becoming 
more deep, eroding, spreading, as well as seldomer healing up. In 
such cases, the eyes are often particularly affected. The edges of 
the eyelids are affected with tumour and superficial ulcerations; and 
these commonly excite obstinate inflammation in the adnata, which 
frequently produces an opacity in the cornea. 

"When the scrofula especially affects the joints, it sometimes pro- 
duces there considerable tumours; in the abscesses following which, 
the ligaments and cartilages are eroded and the adjoining bones are 
affected with a caries of a peculiar kind. In those cases, also, of 
more violent scrofula, while every year produces a number of new 
tumours and ulcers, their acrimony seems at length to taint the whole 
fluids of the body, occasioning various disorders and particularly a 
hectic fever with all its symptoms, which at length proves fatal, with 
sometimes the symptoms of a phthisis pulmonalis. 

" The bodies of persons who have died of this disease, show many 
of the viscera in a very morbid state, and particularly most of the 
glands of the mesentery very much tumefied and frequently in an 
ulcerated state. Commonly, also, a great number of tubercles or 
cysts, containing matter of various kinds, appear in the lungs. 

"Such (says Cullen, par. 1750,) is the history of the disease; and 
from thence it may appear that the nature of it is not easily to be 
ascertained." 

Treatment of scrofula. — In describing the treatment of scrofula, 
I shall confine myself to that which is necessary in glandular affec- 
tions and superficial ulcerations, as the diseases of the eye and the 
lungs have been already considered, and as those of the bones belong 
more to the province of surgery. Nevertheless the constitutional 
treatment that I shall recommend, is equally applicable to all forms 
in which the disease occurs. We are told by almost every author 
"to correct the bad habit of body," and improve the state of the 
constitution ; but, as far as I am aware, we have never yet been 
told a proper method to bring about this desirable event, or, indeed, 
in what the bad habit of body consists. Mr. Lloyd appears to me 
to have arrived nearer the truth in this respect than any other writer, 
but how much of his information has been drawn from Mr. Aber- 
nethy it is not easy for me to say. 

" From repeated observations, however, (says Mr. Lloyd,) I am 
convinced that there is always a disordered state of health antece- 
dent to those changes in the structure of parts, which are called 
scrofulous diseases, whether they are the effect of an acquired or 
of an hereditary tendency; and, therefore, that our treatment must 
be always founded on the same principles: so, of course, it must 
be modified according to any particular circumstances which may 
attend particular causes." — (Page 26.) In other places of his work, 
he attributes this condition to more or less disorder of the digestive 
organs, which, he says, will always be found to have existed for 
some time previous to the appearance of the disease in any particu- 
lar part. This will be distinctly observed in the following paragraph, 
(at page 33.) — "From the nature of the constitutional disorder that 
attends and precedes this disease, we might be induced to believe 



SCROFULA. 849 

that the disease entirely depended upon the disorder of the digestive 
organs, produced by various causes acting immediately on them, or 
mediately through the nervous system." Nevertheless, Mr. Lloyd 
has failed to show what the true nature of the disorder is, or its pre- 
cise seat, or, I may add, a more successful mode of treatment than 
his predecessors. 

Dr. Cullen states, in paragraph 1753, that "for the cure of scrofula, 
we have not yet learned any practice that is certainly or even gene- 
rally successful. The remedy which seems to be the most successful, 
and which our practitioners specially trust to and employ, is the use 
of mineral waters; and, indeed, the ivashing out, by means of these, 
the lymphatic system, would seem to be a measure promising suc- 
cess." 

A great number of specifics have been recommended for the cure 
of scrofula, the chief of which are bark, mercury, steel, mineral 
waters, barytes, lime-water and muriate of lime; but experience has 
shown that they are not worthy of much confidence, and some of 
them are represented to have been injurious. I was once very much 
amazed on hearing the answer given by a physician in my presence 
to a lady, who was desirous of knowing how long her little girl was 
to be compelled to take the solution of the muriate of lime. She 
stated that it was a very nauseous medicine, and that it had done 
the child no good, although she had taken it regularly for six months. 
The physician replied that it would probably require three or four 
years before it would produce any beneficial effects, and that it must 
be regularly taken. Whether the physician spoke believing what 
he said to be true, I cannot pretend to say, but he looked grave 
enough. 

lodging from the condition of the tongue, from the appetite, the 
increased ilnr.st, the tumefaction of the abdomen, the degree of flatu- 
lency, the occasional pain in the belly, the irregularity of the bowels 
and the appearance of the feculent matter, 1 persuaded myself, many 
years ago, that scrofulous affections were produced by disease in the 
digestive organs, and that that disease, whatever else il might be 
ng i", cousisted principally in extensive irritation and inflamma- 
tion of the mucous membrane. But I had little notion thai fre- 
quently there were extensive ulceratione, till 1 was repeatedly con- 
vinced by dissection that it was the case — since which tune I have 
treated the disease in the following manner, and with much success. 

If, along with considerable gastro-intestinal irritation, there be 
much fever at night, the Strength being as yet unbroken, leeches 
ought to I".- applied to the abdomen, in Bueh number as the symp- 
toms, strength and slate of the constitution require; the bowels 
should be kept gently open, but drastic purgatives are on no account 
to be exhibited. Contra-irritation should be produced on the abdo- 
domen by means of stimulating embrocations, or by what is still 
better, tartar-emetic ointment ; and if an opiate be required to allay 

the irritation of the bowels, perhaps the best remedy will be B lew 

grains of Dover's powder. It is, probably, in such eircurastanoes 

that lirne-waler has been found beneficial, as it is ;i remedy Ol con- 
siderable power m this particular state of the mucous membrane. 

11" 



850 SCROFULA. 

The diet must be rigidly attended to, and varied according to cir- 
cumstances. When the tongue is loaded and red round the edges, 
or universally red, the patient should be restricted to gruel, arrow- 
root, whey and the like, as the digestive powers will not be able to 
assimilate any other kind of food. Soups and animal jellies, which 
are so often had recourse to, prove very injurious, and aggravate the 
evils which it is our object to prevent. But when the marks of irri- 
tation in the stomach and bowels subside, when the tongue becomes 
clean, and the stomach more vigorous, a small quantity of chicken, 
or any other kind of meat, should be allowed, care being always 
taken that the patient shall take no more than the stomach can easily 
manage. If he do, the mischief will be soon announced by acidity, 
heartburn, troublesome distension of the stomach and a feverish 
night. For some days after such an occurrence, the articles of diet 
mentioned above should be used. 

Calomel or blue pill is to be administered only when the tongue 
is furred, although there can be no objection either to an occasional 
grain or two of calomel or of blue pill, to act as a gentle laxative. 

The great error of the system pursued by Mr. Abernethy and his 
disciples, arises from their giving the blue pill indiscriminately, 
owing, perhaps, to their not being aware that the mucous membrane 
is the seat of the irritation, and that inflammation and ulceration 
sometimes take place. 

The warm bath is to be used every second night, and on the alter- 
nate days the body may be sponged with warm water and vinegar, 
which last is the best remedy when the patient is either very weak 
or when the health and strength are becoming restored. By and by, 
sponging with cold water, the shower-bath, or sea-bathing may be 
substituted. 

Air and exercise are indispensable parts of the treatment, but the 
patient should not be exposed to a raw, cold, damp atmosphere, at 
least till recovery is far advanced, and not even then, unless the 
body be sufficiently protected by warm clothing. Flannel should 
be worn next the skin, and during the winter and spring months a 
leather jacket and drawers should be used in addition to, but outside 
of, the flannel. 

There can be no reasonable objection against the occasional em- 
ployment of mineral acids and tonics, provided they be not persisted 
in too long, or exclusively trusted to as specifics, or used at times 
when leeching and contra-irritation are actually necessary. 

1 cannot avoid doing Mr. Lloyd the justice of transferring the fol- 
lowing judicious passage from his work to these pages: — "When 
there is what is called a weak stomach, with loss of appetite, I have 
often seen the different tonics, as cinchona, steel and the mineral 
acids, of the greatest service; but I am sure, as I have said before, 
that they possess no specific power over scrofula. Moreover, I feel 
certain that a great deal of mischief is often produced by the exhi- 
bition of these medicines in conjunction with a stimulating diet, and 
that diseases which might otherwise be speedily relieved, are, by 
these means, rendered fatal to the patients. Too often have I seen 
medical men, when consulted about children with swelling of the 



SCROFULA. 851 

glands of the neck, or other scrofulous affection, at once declaring 
them in a delicate state of health, prescribe a generous diet, as full 
meals of meat, with porter and wine, with the use of baric, steel, or 
some other strengthening medicines as they are called, merely be- 
cause the disease was scrofula. Too often have I seen this plan pur- 
sued in cases where, on more accurate examination, I have found 
the patient requiring a plan of treatment directly the reverse." — 
(Page 41.) And in another place, alluding to the same treatment, 
he says, " It is true, however, that when children are first put on this 
treatment, they appear to the common observer immediately to im- 
prove in health. A species of fever is produced, the cheeks become 
fuller and flushed, and the exhilarating powers of the stimuli height- 
en the spirits of the child, so that the delighted mother feels greater 
confidence in her doctor, and expects soon to see her child perfectly 
recovered. But too soon, however, these favourable appearances 
are generally proved to be fallacious by the discovery of some fresh 
swelling, or by the child evidently becoming weaker and more irri 
table. It is equally true, too, that when children are put on a differ- 
ent plan of treatment, they often, for the first ten days or a fortnight, 
become paler and perhaps weaker; but after this period, if there be 
no important visceral disease, it will always be found that, the irrita- 
tion of the disease subsiding, they gradually recover strength and. 
flesh, though, perhaps, taking only half the food which they were 
accustomed to before." — (Page 42.) 

These passages merit the greatest attention from those practitioners 
who still follow the line of treatment which Mr* Lloyd condemns; 
and for further particulars, I beg to refer the reader to the chapter 
on Tabes Mesenteries, in the first volume of this work. 

It is now necessary that I should notice a remedy which has been 
found of irreat service in reducing enlarged glands, provided their 
structure be not destroyed by diseased action. This remedy is iodine 
rui'l its various preparations, the effects of which are very wonderful 
in bronchocele, although its administration in scrofulous affections of 
tip- glands bas mot been attended with the universal success which 
was at one tune anticipated. Nevertheless, it is a preparation which 
is in many instances highly serviceable, but winch requires judgment 
and discrimination. Iodine is of no service if there be much gastro- 
intestinal irritation, <>r ;i loaded tongue, or if the gland be in a state 
of inflammation. Hence it is thai it has been found so beneficial in 
chronic indolent swellings, as in bronchocele, and that its operation 
has been observed in many cases to be more rapid when its use is 

conjoined with local bleeding. Preparations of iodine are n> he. used 
in th<: manner already described when treating of diseases of the 
uterus. 

Lara/ treatment of the scrofulous affections of the glands, — It 
is to be apprehended that serious injnry has been inflicted on indi- 
viduals by the absurd plan of trying to "put hack*' glandular 

tumours by cold applications of various kinds. When the tumours 

are small and not painful, little iced he done except covering the 
part wuh flannel, or rubbing them with an ointment containing 

iodine. But should there be any lnllainmation, warm fomentations, 



852 SCROFULA. 

or poultices ought to be applied, and an opening made as soon as 
fluctuation is discovered. Dr. James Hamilton, jun., the professor 
of midwifery in this university, has great merit for being among the 
first who insisted upon the advantage of making an early opening; 
and he used to take particular pains to show that so far from leaving 
a mark, an early puncture was the best means for preventing such a 
disagreeable circumstance. By making the incision, we shall prevent 
the formation of those small apertures which so frequently run into 
extensive ulcerations; and we always find that the longer the part 
is inflamed, and the more distended it becomes, the subsequent ulcer- 
ations are more extensive, indolent and difficult to heal. When the 
gland is deep seated, there is a greater necessity for letting out the 
matter. But should the glandular swelling be very much inflamed 
and tender from the first, or become so at any time before matter is 
formed, leeches are to be applied to moderate the violence of the 
inflammation, and prevent the abscess from becoming so large as it 
-would undoubtedly do if left to run its course. 

In the event of our not being called till ulceration has taken place, 
besides attending to the constitutional treatment already so fully 
described, we must have recourse to the application of various 
remedies. Some cases of indolent ulcer assume a healing tendency 
under the application of the black wash, or a solution of the acetates 
of lead or zinc, but it should be applied warm, and not persisted in for 
more than two or three days. In other cases, whether the sores are 
either indolent or irritable, lunar caustic will be found to have the 
best effects; and the reason why it has failed so often is, that proper 
constitutional remedies have not been employed at the same time. 
In some cases, immediate benefit will be derived from the application 
of an ointment of the acetate of copper, in the proportion of two, four 
or six grains of the acetate to a drachm of simple cerate. From ex- 
perience, I can speak highly of the effects of pressure. In a case of 
deep and extensive scrofulous ulceration of the mamma, of above 
fourteen years standing, the part assumed a healing tendency in a 
few days after the application of a graduated pressure, and was 
completely cicatrized in rather less than six weeks; and I could, 
mention manv other successful cases. 



CHAPTER IV. 
DROPSY. 

GENERAL REMARKS. 

An unusual collection of serous or watery fluid in any part of the 
body, is called a dropsy; and is observed to take place in the cellu- 
lar tissue and in serous cavities. Hence we find it in the general cel- 
lular membrane, which is extended over the surface of the body- 
in the lungs, where the air-cells and blood-vessels are enveloped by 
a loose cellular tissue — within the membranes of the brain — in the 
pericardium — and in the cavities of the pleura and peritoneum. 
Dropsy has therefore received distinct appellations, according to the 
locality of the effusion; and, in noticing these circumstances, Dr. Cul- 
len observes, (par. 1645,) that "although the particular instances of 
such collection are to be distinguished from each other according to 
the parts they occupy, as well as by other circumstances attending 
them, yet all of them seem to depend upon some general causes, 
very much in common to the whole. Before proceeding, therefore, to 
consider the several species, it may be proper to endeavour to assign 
the general cause of dropsy." I shall pursue the same course as 
Dr. Cnllen, who. althoagh he seems to have directed considerable 
attention towards the acquirement of an intimate knowledge of the 
morbid alterations found in different organs in dropsy, yet was too 
anxious to insist upon ;i loss of tone in the absorbent extremities of 
the lymphatics ami laxity of the ezhalsnt vessels as causes, to allow 
sufficient influence to internal organic disease, or to a general ple- 
thora <>r inflammatory diathesis. 

"In per,,, us in health (says Dr. Cullen), a serous or watery fluid 
seems to be constantly poured out or exhaled in vapour, into every 
cavity and interstice of the human body capable of receiving it; and 
the same fluid, without remaining long or being accumulated in 
dm constantly to be soon again absorbed from thence 
by vessels adapted to the purpose. From this view of the animal 
imy, u will be obvious, that if the quantity poured out into any 
sp use happens to be greater than the absorbents can at the same time 
Mike up. au unusual accumulation of serous fluid will be made in 
•nth parts; or though the quantity poured oui be not more than 
usual, yet if the absorption be any ways interrupted or diminished, 
from tins i aus,., edoo, an unusual collection of fluid may be occa- 
sioned. 



854 DROPSY. 

" Thus, in general, dropsy may be imputed to an increased effusion 
or to a diminished absorption." (Par. 1645.) 

He considered that increased effusion may happen either from a 
preternatural increase of the ordinary exhalation, or from the rup- 
ture of vessels carrying, or of sacs containing, serous or watery 
fluids. The ordinary exhalation may be increased from an inter- 
ruption which resists the free passage of the blood from the arteries 
into the veins, which interruption increases the force of the arterial 
fluids in the exhalents from which the effusion takes place. This 
interruption may be owing to the following circumstances; disease 
of the heart, particularly certain conditions "in the right ventricle of 
the heart itself," which prevents it from receiving the usual quantity 
of blood from the veins to obstructions in the vessels of the lungs, 
preventing the entire evacuation of the right ventricle, and thereby 
hindering its receiving the usual quantity of blood; "thus, (says he,) 
a polypus in the right ventricle of the heart, and the ossification of 
its valves, as well as all considerable and permanent obstructions in 
the lungs, may be considered as causes of dropsy." (Par. 1649.) 

The only additions which can be made to these last observations 
are, that it is now well known every kind of organic disease of the 
heart and of its valves may give rise to dropsical effusion, if the 
patient be not cut off early in the complaint ; and there can be no 
doubt, also, that all considerable and permanent obstructions to the 
circulation in the lungs will occasionally give rise to dropsy; but, in a 
practical point of view, it is important to know that chronic bron- 
chitis is the diseased condition of those organs on which it most fre- 
quently depends. But in either of these cases, there is something 
more to account for the dropsical effusion, than the mere obstruction 
to the circulation — the functions of the lungs are embarrassed, and. 
the blood itself does not undergo those changes which are necessary 
to constitute health. 

Dr. Cnllen supposed that "it may serve as an illustration of the 
operation of these general causes, to remark, that the return of the 
venous blood is in some measure resisted when the posture of the 
body is such as gives occasion to the gravity of the blood to oppose 
the motion of it in the veins, which takes effect when the force of 
the circulation is weak; and from whence it is that an upright pos- 
ture of the body produces or increases serous swellings in the lower 
extremities." (Par. 1650.) It appears more probable, however, 
that the collection of serum in the lower extremities is rather to 
be attributed to the fluid gravitating from superior parts to those 
most depending, than to an increased effusion from the vessels aris- 
ing from the posture of the body, and the weakness of the circula- 
tion. 

" Not only (continues Dr. Cullen) those causes interrupting the 
motion of the venous blood more generally, but further, the interrup- 
tion of it in particular veins, may likewise have the effect of increas- 
ing exhalation and producing dropsy. The most remarkable in- 
stance of this is, when considerable obstructions of the liver prevent 
the blood from flowing freely into it from the vena porlarum and its 



DROPSY. 855 

numerous branches, and hence these obstructions are a frequent cause 
of dropsy. " (Par. 1651.) 

"Scirrhosities of the spleen and other viscera, as well as the scir- 
rhosity of the liver, have been considered as causes of dropsy; but 
the manner in which they can produce the disease, I do not perceive, 
except it may be when they happen to be near some considerable 
vein, by the compression of which they may occasion some degree 
of ascites; or, by compressing the vena cava, may produce an ana- 
sarca of the lower extremities." 

Dr. Cullen also thought that, even in smaller vessels, the interrup- 
tion to the motion of the blood, in particular veins, has a similar 
effect: "Thus a polypus formed in the cavity of a vein, or tumours 
formed in its coats, preventing the free passage of the blood through 
it, have had the erfect of producing drospsy in the parts towards the 
extremity of such veins." (Par. 1653.) 

'•'But the cause most frequently interrupting the motion of blood 
through the veins, is the compression of tumours existing near to 
them ; such as aneurisms in the arteries, abscesses and scirrhous or 
Steatomatous tumours in the adjoining parts. To this head may be 
referred the compression of the desendmg (ascending) cava by the 
bulk of the uterus in pregnant women, and the compression of the 
same by the bulk of water in the ascites; both of which compres- 
sions frequently produce serous swellings in the lower extremities." 
(Par. 1654.) 

The statements contained in the above paragraphs appear to me 
to be far too mechanical. When an obstruction takes place in the 
liver, it proceeds either from abscess, tubercular formation or scir- 
rhous degeneration ; consequently, the functions of the organ must be 
embarrassed to a greater or less extent ; the mesenteric blood which 
passes through it cannot undergo the necessary changes, and must 
therefore operate prejudicially on the system at large. Besides, if 
dropsy were owing to the mere mechanical obstruction, preventing 
tiie blood from flowing freely through the vena portaruui, ascites only 
should be the consequence, and not general dropsy. With respect 
to Dr. Cullen's observations concerning the compression produced by 
the gravid uterus, and that occasioned by the bulk of water in ascites, 
as being the frequent causes of oedema in the lower extremities, it 
may be further remarked that, in many cases, the embarrassed func- 
tions of the kidneys will be found to be the cause of the effusion ; and 
that, by increasing the flow of mine in the former, the swelling in the 
extremities will permanently disappear, although the uterus goes on 
for months increasing in bulk as well as in weight. In some' of the 
most exquisite examples of dropsical elfusion, confined to the cavity 
of the abdomen, which have fallen Under my observation, no u'dema 

of the lower extremities took place. I have often made a similar 
Btmark, in cases of enlarged ovaria and other uterine tumours, in 

many of which the pressure must have been more considerable than 

either during gravidity 01 ascites. 

Dr. Cullen SMO 10 have forgotten that) in the case of mero ob- 
struction in any one particular vein, unless it he the trunk leading 
from an extremity, the blood which ought to pass through it will tind 



856 DROPSY. 

its way by some other route. The crural and iliac veins have been 
found not only obstructed, but diseased, in cases of phlegmasia do/ens, 
in which, instead of oedema of the limb, a general inflammatory af- 
fection is produced in it; and although the nature of the disease has 
not yet been fully investigated, all the phenomena in the limb are 
different from those accompanying oedema. 

"It may be supposed (says Dr. Cullen, par. 1655), that a general 
preternatural plethora of the venous system may have the effect of 
increasing exhalation ; and that this plethora may happen from the 
suppression of fluxes or evacuations of blood, which had for some 
time taken place in the body, such as the menstrual and hemorrhoidal 
fluxes. A dropsy, however, from such a cause, has been at least a 
rare occurrence, and when it seems to have happened, I should sup- 
pose it owing to the same causes as the suppression itself, rather than 
to the plethora produced by it. 

"One of the most frequent causes of an increased exhalation, I 
apprehend to be the laxity of the exhalent vessels. That such a 
cause may operate, appears probable from this, that paralytic limbs, 
in which such a laxity is to be suspected, are frequently affected with 
serous, or, as they are called, oedematous swellings. 

" But a much more remarkable and frequent example of its opera- 
tion occurs in the case of a general debility of the system, which is 
so often attended with dropsy. That a general debility does induce 
dropsy, appears sufficiently from its being so commonly the conse- 
quence of powerfully debilitating causes, such as fevers, either of the 
continued or intermittent kind, which have lasted long; long-con- 
tinued, and somewhat excessive evacuations of any kind; and, in 
short, almost all diseases that have been of long continuance and have 
at the same time induced the other symptoms of a general debility. 

"Among other causes inducing a general debility of the system 
and thereby dropsy, there is one to be mentioned as frequently oc- 
curring, and that is, intemperance in the use of intoxicating liquors, 
from whence it is that drunkards of all kinds, and especially dram- 
drinkers, are affected with this disease. 

"That a general debility may produce a laxity of the exhalents 
will be readily allowed : and that by this especially it occasions 
dropsy, I judge from hence, that while most of the causes already 
mentioned are suited to produce dropsies of particular parts only, the 
state of general debility gives rise to an increased exhalation into 
every cavity and interstice of the body, and therefore brings on a 
general disease." 

It appears to me that the illustrations which Dr. Cullen has used 
in proof of the laxity of the exhalent vessels, which he considers the 
chief circumstance in the pathology of dropsy, and therefore terms 
the hydropic diathesis, are most unfortunate. If they were correct, 
we should invariably see paralytic limbs cedematous, which is far 
from being the case. With respect to fevers, whether continued or 
intermittent, which have lasted long, we may certainly expect occa- 
sionally to see dropsical affections, not so much from debility, how- 
ever, as from changes in the structure of internal organs : and, lastly, 
as to intemperance, and especially dram-drinking, these habits no 



DROPSY. 859 

manently changed, either in accordance with, and in furtherance of, 
that morbid action, or by a deposit which is the consequence of the 
morbid action, but has no share in that arrangement of the vessels on 
which the morbid action depends. 

"The observations which I made respecting the condition of the 
urine in dropsy, are, in a great degree, in accordance with what has 
been laid down by Dr. Blackall to his most valuable treatise. 

" Where anasarca has come on from exposure to cold, or from 
some accidental excess, I have, in general, found the urine to be coa- 
gulable by heat. The coagulation is in different degrees; it likewise 
differs somewhat in its character; most commonly when the urine 
has been exposed to the heat of a candle in a spoon, before it rises 
quite to the boiling point, it becomes clouded, sometimes simply opal- 
escent, at other times almost milky, beginning at the edges of the 
spoon, and quickly meeting in the middle. In a short time the coa- 
gulating particles break up into a flocculent or a curdled form, and 
the quantity of this flocculent matter varies from a quantity scarcely 
perceptible floating in the fluid, to so much as converts the whole 
into the appearance of curdled milk. Sometimes it rises to the sur- 
face in the form of a fine scum, which still remains after the boiled 
fluid has completely cooled. There is another form of co;igulable 
urine which, in my experience, has been much more rare; when the 
urine on being exposed to heat, assumes a gelatinous appearance, 
as if a certain quantity of isinglass had been dissolved in water. I 
hive, indeed, met with this in one or two cases only. 

" During some part of the progress of these cases of anasarca, 1 
have, in almost all instances, found a great tendency to throw off the 
red particles of the blood by the kidneys, betrayed by various degrees 
of heernaturia from the simple, dingy colour of the urine, which is 
easily recognized; or the slight, brown deposit, to the completely 
bloody urine, when the whole appears to be little but blood, and 
when not unfrequently a thick, ropy deposit is found at the bottom 
of the vessel." 

And again he states: "In all the cases in which I have Obtained 
the albuminous urine, it has appeared to me that the kidney has 
itself acted a more important part, both functionally and organically, 
than has generally been imagined." 

Gate I. — In thr first owe, published by Dr. Bright, Of anasarca 
with eoagtllable urine, there were mark's of pericarditis ; the heart 
was large and firm ; a triangular and solid deposit of bone was found 
in the angle between two of the sortie valves; the left long adhered, 
and was m every part convened Into a gray hepatr/ed structure, very 
few portions admitting partially the entrance of air; the rigtii lung 
was osdematous, and surrounded but not compressed by effusion of 

serum ; there weir some marks of former inflammation on the peri- 

toneal coal of the liver; the spleen was dark-coloured, with a slight 
adventitious covering like that on the liver. The kidnbts were 
completely granulated throughout; externaHy the surface was rough 

and uneven j internally all traces of the natural organisation nearly 
gone, except in the tubular parts, which were of a lighter and more 



860 DROPSY. 

pink colour than usual. The granulated condition of the kidney was 



Case II. — On dissection the kidneys were both found of unusual 
size, certainly half as large again as most commonly seen, but the 
right was the largest. On an external view they were obviously 
granulated, with a large proportion of yellow granular matter; on 
taking off the proper tunic, this was more distinctly seen; and on 
cutting in, the whole of the cortical structure seemed to be converted 
into a yellow substance in appearance like fat in many parts; though 
in other parts the change had not gone so far. In this case the urine 
was coagulable. 

Case III. — In this case, which was connected also with some de- 
gree of coagulability of the urine, the kidneys were found in the 
following condition. Externally, somewhat misshapen from the 
tubercular character of their structure; the form did not depend upon 
any disease analogous to true tubercles, but upon a general change 
in the substance of the kidney, some parts projecting, of a white 
colour upon a pinkish ground, the small star-like vessels running 
over them. The size was but little altered ; the proper tunic adhered 
very closely. Internally, the whole cortical structure was of a pretty 
uniform yellowish colour, with many small, opaque, and indistinct 
yellow spots. 

Case IV. — The urine coagulated by heat was of a brown colour, 
apparently from a mixture of the red particles of the blood ; and the 
kidneys afforded, on dissection, throughout the whole cortical struc- 
ture, a curious specimen of disease, apparently the commencement 
of granulation ; they were rather large and soft ; their general colour 
was pale, and on taking off the tunic, the whole surface was seen 
speckled with minute yellowish bodies; on making a longitudinal 
section, the same bodies were seen pervading the whole cortical 
substance, assuming, near the surface, somewhat of the striated 
arrangement observed in the structure of the kidney at that part, and 
irregularly disseminated through the other parts. 

Case V. — The urine coagulated strongly by heat; and the kid- 
neys were found large, very dark on their upper surface; on the 
lower mottled with yellow; no elevated granulation to be seen ex- 
ternally, but many small yellow specks. Internally, the substance 
was remarkably pale, and had assumed the appearance of a fatty 
substance, with some traces of a granulated structure throughout: 
this, however, depended in part on a flaky opaque matter thickly 
disseminated; and this same appearance became very obvious over 
the whole external surface after the kidney had been kept in pure 
water for a day or two. 

Case VI. — The kidneys afforded very fine specimens of the con- 
firmed granulated change. They were rather large and bulky; the 
granulation was seen externally over every part of the surface, even 



DROPSY. 861 

before the tunic was removed. The granular bodies were small, of 
a yellow colour, and the surrounding substance more pink. On cut- 
ting longitudinally through the kidney, it was seen that the whole 
cortical substance was composed of the same altered structure, 
and the striated arrangement near the surface was almost lost. Dr. 
Bright gives no account of the state of the urine, as he did not see 
the patient. 

Case VII. — The urine was scanty, and coagulated very considera- 
bly on the application of heat, becoming first milky and then loaded 
with a great number of flakes ; and on dissection the kidneys were 
found small, rather lobulated, of a semi-cartilaginous hardness, com- 
pletely granulated ; the small whitish or yellow granules projecting 
with red, intervening spaces, so as to form a scabrous surface, both 
appearing and feeling rough. On making a longitudinal section, the 
kidney cut with the resistance of a scirrhous gland ; the tubular part 
was drawn much nearer to the surface than is natural: the cortical 
part indistinctly granulated throughout, of a grayish drab mixed with 
purple. 

Case VIII. — The urine was of a deep yellow colour, clear, and 
Coagulated in a very marked manner by heat, assuming a white cur- 
dled form ; and on dissection the ktdnets were observed to be very 
small and hard in consistence, feeling most cartilaginous; their pre- 
vailing colour was purplish ; on their external surface they were dis- 
tinctly granulated in texture; and on making a longitudinal section, 
the same was perceptible throughout; it was remarkable that the 
cortical portion was exceedingly thin, so that the distance between 
the termination of the tubular part and the external surface was 
much less than in the healthy organ. 

I\. — The urine was scanty, and when first passed, was clear, 
Imt of a dingy brown colour; it became tnrbid on cooling, grew 
r on tin; application of a gentle heat, and by raising the tempera- 
ture nearly to the boiling point, it coagulated in a very marked 
■ thai n |int nil the appearance of thick treacle-posset On 
examination of the body after death, the kidneys presented most 
ledly tb" granulated structure; this was somewhat marked ex- 
v. the lighter points of the granulation being smaller than Dr. 
M. has often observed •. and, on cutting into the substance, it was 

thai the natural structure was destroyed throughout the whole 

cortical part, which was mottled as in the two las! casesj but ibis 

morbid structure appeared in its most advanced stage around the 

tubular parls. 

\. — At first the urine was scanty, and COagulatdd decidedly, 

though not to the extent nasally observed, and in the progress of the 
tinned very scanty. Sometimes it was tolerably 
dear, ho! became turbid on cooling; at other times it bore the dingy 
colour winch usually denotes the presence of blood ; almost always 
it retained its coagulability, but m general this was limited to a dense 

73" 



862 DROPSY. 

deposit of brownish flakes, the whole fluid not becoming milky or 
curdled On dissection, the kidneys were contracted and hard, and 
on removing their tunic, the surface was scabrous ; but the projecting 
roughness was of a pretty uniform gray, purplish colour, and the same 
was observable on making a section. 

Case XI. — The kidneys were most decidedly diseased. They did 
not feel so firm as natural, were almost white in external appear- 
ance, rather large and lobulated, without any signs of granulation, 
and only showing a few star-like vessels distributed on the surface ; 
otherwise of nearly one even surface, and on most minute inspection 
no mark of structure, as usually seen on the surface of the healthy 
kidney, was discoverable. On making a complete longitudinal sec- 
tion, the same gray-white colour pervaded all the cortical part, with 
little sign of natural structure; the faint appearance which did exist 
preserved those marks of lines proceeding towards the surface, which 
are often more evident in the healthy kidney. The tubular part was 
also faintly coloured. In this case Dr. Bright could not ascertain the 
state of urine. 

Case XII. — The urine was scanty and of a slightly dingy colour, 
coagulating decidedly by heat; and on dissection, the kidneys were 
found disorganized throughout, smooth in their external texture, 
rather lobulated, of a pale yellow colour, with a few superficial vessels; 
and on being examined internally, the same gray yellow colour per- 
vaded the whole cortical part, with some more opaque yellow spots 
irregularly intermixed. The tubular structure pale and indistinct; 
in a word, approaching more to the condition of the kidneys men- 
tioned in the last case than any others. 

Case XIII. — The urine coagulated, was turbid, and became dingy 
as from a slight admixture of blood. On dissection, the kidneys very 
pale and rather soft, discovered externally nothing but the natural 
structure, rather more marked than usual, but internally was plainly 
to be traced a motley granulation, very small and faint in its colour 
and markings. 

Case XIV. — The urine coagulated by heat more or less during the 
course of the disease, had a dark brown tinge, being a mixture of 
the red particles, and at length became quiet red, depositing a quan- 
tity of ropy mucus. On dissection, the kidneys presented a very 
curious appearance. They were easily slipped out of their investing 
membrane, were large and less firm than they often are, of the 
darkest chocolate colour, interspersed with a few white points, and 
a great number nearly black ; and this, with a little tinge of red in 
parts, gave the appearance of a polished fine-grained porphyry or 
green stone. On cutting longitudinally into the kidney, this structure 
and these colours were found to pervade the whole cortical part; 
but the natural striated appearance was not lost ; and the external 
part of each mass of tubuli was particularly dark; the whole mam- 
millary processes were also of a dark colour. On being cut through 



DROPSY. 863 

md left for some time, a very considerable quantity of blood oozed 
lrom the kidney, showing a most unusual accumulation in the organ; 
and, indeed, it seemed to be from this cause that the peculiar appear- 
ance and colour arose, the very dark spots being the effect of blood 
either extravasated,or in vessels greatly gorged. 

The immediate cause of death in this individual seems to have 
been oedema g lot t id is. 

Having now extracted from Dr. Bright's work the principal dis- 
eased appearances in the kidneys, I shall proceed to give short ex- 
tracts from the second part, of some of the appearances of the liver 
and gall-bladder, connected with dropsical effusion. 

" Although (says Dr. Bright), I am strongly impressed with the 
belief that many cases of dropsy have been supposed to depend on 
disease of the liver, when the kidneys have, in fact, been chiefly in 
fault; yet there is little doubt that, in many other cases, the liver is 
the real cause of the dropsical effusion, frequently showing most ex- 
tensive disease when the kidneys are quite healthy. 

u I have already remarked, when relating the cases of anasarca, 
connected with organic disease of the kidneys, that the liver has sel- 
dom been perfectly healthy, though the deviation from the natural 
structure has often been so slight, as to render it doubtful whether it 
should be noticed amongst the morbid appearances : and in describing 
this state, I have sometimes used the expression that the liver showed 
a tendency to granulation. The fact is, that the liver, in these cases, 
has usually preserved its natural figure; the acute margin has been 
perfect, and the general size has not been augmented ; the perito- 
ii'iiin has been quite transparent, and attached only in the ordinary 
degree to the viscus ; the texture of the liver has neither been unna- 
turally firm nor morbidly flaccid; but, on examining the surface, it 
has been evident that the colour was less uniform than in perfect 
health; Ihe whole was marbled, consisting of very small light spots 
in a i iind; hut on making a section perpendicular to the 

surface, though the same general variety of colour has been observed) 
yet in some pacta of tin' section it has been doubtful whether the 
darker or 1 1 j ♦ - lighter pari should be considered as the groundwork; 
in general, however, by attentive observation, it will he found, that 
in the centre of the lighter spois small depressions or openings are 
visile, and that the darker parts appear to he ihr connecting medium 
of the lighter parts, which seem to he the acini of the glandular struc- 
ture. Although, in most casts, these appearances scarcely attract 
■Mention, yet m other cases they become more obvious, either the 
white portions becoming lamer in proportion, or the whole viscus 

appearing 10 have lost a little of its natural pliability, to have become 

bard, and to breakdown with a slightly granulated fracture. I have 

eiy, m any instance, seen this derangement of the liver go far- 
mer, except m the Case of Sn.w akt. where most decided morbid 

change had taken place, 'lie- liver bad assumed more of a tabulated 

form than in health, and the acute margin had become rounded. In 
all t!. , the secretion of bile is tolerably natural, the u a 1 1- blad- 

der being well supplied with bile of a sufficiently dark yellow colour 

Besides ibis moie common appearance of the liver in the class of 



864 DROPSY. 

dropsies of which I have been treating, the liver has occasionally de- 
viated a little in its consistence from its natural state, being either too 
firm or too flaccid ; but where this has been the case, the deviation 
has only been such as is constantly occurring in cases where neither 
effusion nor any other marked symptom of disease has arisen during 
life. From the very prominent place which the disease of the kid- 
ney has appeared to hold in these cases, I have been inclined to con- 
sider the derangement of the liver as a secondary effect, or at least a 
subordinate disease, though not impossibly the state of both these 
organs depends on the same general constitutional affection; and I 
have sometimes even thought that the tendency to granulation, where 
it existed, maintained a certain relation in its progress to the disease 
of the kidney. 

"There are, however, hepatic derangements, unaccompanied by 
obvious disease of other organs, which may probably with justice be 
considered as laying the foundation of dropsical effusions. And of 
these, I shall now detail a few examples, in which it will be seen 
that the morbid appearances presented by the liver are very various, 
arising, as it would seem, from morbid actions, essentially differing 
from each other." 

Case XXV. — "Liver contracted, and throughout of a morbid 
structure, apparently by the deposition of minute portions of a yel- 
low matter. The surface, covered by a very fine peritoneum, quite 
transparent, even more thin than usual, presenting a rough, granular, 
and therefore uneven surface, of what might be called liver-coloured 
red and yellowish gray. On being cut into, the same structure of a 
less red colour pervaded the whole. The liver was thicker and 
rounder than natural, and rather smaller; and on pressure broke 
down easily, with a brittle or crisp fracture, uneven and granular. 
The gall-bladder, opaque and thick, containing the usual quantity of 
bile. The common duct was pervious, but at its entry into the duo- 
denum, was contracted in a nipple-like projection, with an orifice not 
much larger than to admit the point of a pin. On opening the gall- 
bladder and letting out the deep-coloured viscid bile with which it 
was filled, a number of small yellow bodies, larger than millet-seeds, 
and soft, adhered to the villous surface of the gall-bladder, chiefly on 
the side where it is attached to the liver." The urine, in this case, 
did not coagulate on the application of heat. 

Case XXVI. — "The liver externally tuberculous, of a light yellow 
colour nearly approaching to that of a lemon, with deep fissures in 
the surface, apparently arising from partial contraction taking place 
in the substance of the organ, and partly depending on the contrac- 
tion of the thin adventitious membrane which covered the perito- 
neum. The whole liver was enlarged about one-third above its 
natural size; it was greatly increased in firmness and specific gravity; 
it felt firm and hard ; cut with considerably more resistance than 
boiled udder, to which it might be said to bear some general resem- 
blance ; and on examination, its whole structure was composed of 
bright yellow granules distributed in a transparent pinkish ground, 



DROPSY. 865 

the two parts bearing about an equal proportion; and although on 
the surface the pinker part appeared the basis, yet in the section the 
yellow rather seemed to be so. The two parts did not separate, or 
in this respect resemble one body imbedded in another ; nor was 
there any appearance of tubercular structure in the substance of the 
organ. The gall-bladder very much contracted, containing a small 
quantity of dirty-looking bile." Urine not coagulable by heat. 

Case XXVII. — "The substance of the liver hardened throughout, 
the structure nearly resembling scirrhus, with bands of thickened, 
cellular membrane like ligamentous matter pervading every part, and 
in some parts forming one-third of the whole structure; although 
when seen externally the liver appeared tuberculous and knotty, yet 
when examined internally there were no tubercles. The outside 
was smooth, though not even, and on pressure between the fingers, 
gave almost the resistance of cartilage. A piece of the substance 
taken without the peritoneal and adventitious membrane, was still 
so hard as not to be broken down by the same pressure; there were 
some adhesions, old but web-like, between the liver and diaphragm. 
The gall-bladder was contracted, and covered by the false membrane; 
it contained bright yellow bile, and the ducts were pervious." Urine 
not noticed. 

Case XXVTII. — "The liver was drawn up under the diaphragm 
to which it was fixed by a firm old adhesion ; it was stiff and rigid, 
and being covered with the adventitious membrane, bore no resem- 
blance to a natural liver. It was contracted in size, and throughout 
every part extremely hard, so as to cut with difficulty, and almost 
with a cartilaginous resistance* It was of a speckled yellow green, 
with lighter bands running through it, but these bearing a small pro- 
portion to the whole. It was compared by some to a decomposing 
coarse-grained sand-Stone, and would not break down under any 
Ordinary pressure of the fingers. The gall-bladder of tolerable size, 
and moderately filled with viscid yellow bile, which, when seen in 
the ma^s. appeared of its full dark colour; indeed, 1 should say that 
it was by ii" means unhealthy bile. There were &ve gall-stones in 
tlii- bladder the size of peas which appeared like inspissated bile." 
hi this ease, there .WAS evidently chronic peritonitis, and the omen- 
tum was dense and hard. The kidneys were healthy in structure. 
The urine did not coagulate by heat. 

< \.\l\. — "The liver was found to have undergone nearly 

tie' same change as that described in Case XXVII. — Tin- kidneys 

were large, and in a very unhealthy condition, quite dissolved and 

watery in their, texture, with light yellow stripes through the cortical 

OH-,-. The nnii'- w.is high-coloured, coagulating a little on the 

Application <>l beat, v " as to become, for a short lime, turbid, and then 
let fly a flaky deposit* leaving the fluid clear." 

\ \ \. — '• The live! was drawn up almost entirely within the 
concavity of the diaphragm, to which it was attached by several 



866 DROPSY. 

very firm cord-like organized adhesions. This organ, throughout its 
whole substance, was quite changed in structure, as if in progress of 
becoming uniformly tubercular; its whole structure changing into 
small round masses of the size of large peas, not much altered from 
its natural colour, but capable of being picked out, leaving imperfect 
cavities. The gall-bladder was very small, and at least twenty times 
its natural thickness, opaque yellow, but containing a small quantity 
of bile ; the ducts pervious. There was, besides, considerable disease 
of the peritoneum and intestines, and the spleen was four times the 
natural size. The kidneys, though large, were not unhealthy." The 
state of the urine is not noticed. 

Case XXXI. — " The liver was rather contracted in size, of a yel- 
lowish drab-colour externally, the whole granulated in appearance, 
so as nearly to resemble a coarse-grained sand-stone, of which the 
component granules projected slightly on the surface, and were gene- 
rally about the size of small lupine seeds, varying a little in colour — 
gray, brownish and yellow. The liver was somewhat tough, and 
gave considerable resistance to the knife : the altered structure per- 
vaded the whole, and the rounded bodies were formed into clusters, 
many of which were of a light yellow colour; and this was particu- 
larly remarkable near the acute margin. The gall-bladder was dis- 
tended with watery bile. The kidneys had a few vesicles in the 
substance of the cortical portion ; otherwise their structure and con- 
sistence were perfectly healthy; and on stripping off the tunic, they 
presented a smooth and yielding surface." The state of the urine 
is not noticed. 

Two or three other cases are subjoined in Dr. Bright's work, but 
I shall pass them over. I hope the appearances already described, 
of alteration in the structure of the kidneys and liver, will be a guide 
to my readers in making similar investigations; and will induce them 
to peruse the work of Dr. Bright, from which they will derive much 
pathological and practical information. 

My attention has long been attracted to diseases of the liver, 
peritoneum, heart and lungs, in connection with dropsy; and my 
portfolio contains many drawings in illustration of these appearances; 
but it is only within these few years, since Dr. Bright's work ap- 
peared, that it was directed to the morbid structure of the kidneys. 
Since the publication of the last edition of this work, several cases 
have fallen under my observation, in which the kidneys presented 
the exact appearances so beautifully delineated by Dr. Bright. Some 
of these cases were dropsical, others not. These disorganizations of 
the kidneys are, for the most part, however, connected with dropsical 
effusions, and are announced by scanty secretion of urine of low 
specific gravity, containing a large quantity of albumen and a dimi- 
nished proportion of urea. At the same time, I must state the fact, 
that I have several times seen the urine coagulable by heat, the 
specific gravity low, (109°,) along with general dropsical diathesis, 
and yet the patients recovered perfectly; which could not have taken 
place had the kidneys been disorganized. I cannot but conclude, 
therefore, that the urine may be in this condition, and dropsical effu- 



DROPSY. 867 

sions may take place from functional disorder of these organs, as well 
as from organic lesions. 

The profession owes much to the labours of Dr. Bright, and it is 
deeply to be deplored that other hospital physicians, with similar ad- 
vantages, have not made the same good use of their opportunities. 

General remarks on the symptoms of dropsy. — In this place, it 
is my intention to give a slight sketch of the general symptoms which 
accompany dropsical compfaints, reserving those which are peculiar 
to effusions in the thorax, abdomen, &.c, until I come to treat of the 
particular forms of dropsy. The general symptoms are, a sallow 
complexion; dry skin; costive bowels; urine in small quantity and 
of a high colour, in some cases coagulable by heat, and of low spe- 
cific gravity ; muscular emaciation ; general debility ; febrile symp- 
toms particularly towards night ; want of appetite and indigestion, 
and sometimes nausea, vomiting and diarrhoea. In some cases there 
are cough, difficulty of breathing, particularly in the horizontal pos- 
ture, and occasionally expectoration. Sometimes there are a sense 
of suffocation, violent palpitation and startings during sleep. The 
pulse is sometimes slow, at others quick, often irregular and intermit- 
ting; the tongue is sometimes furred and moist, at others parched 
and red and sometimes it is preternaturally clean and florid. Occa- 
sionally erysipelatous inflammation takes place, or the skin cracks, 
allowing a watery fluid to ooze out. 

The duration of dropsy is very various, and depends almost 
entirely upon the nature of the disease, by which the effusion is 
caused. 

General remarks on the treatment of dropsy. — Among the re- 
medies employed in dropsy, the consideration of blood-letting is the 
most important; because it is indispensably necessary in some cases, 
while its employment is doubtful in others, and would be decidedly 
injurious in many. In the treatment of dropsy, many insurmounta- 
ble obstacles are experienced in investigating and deciding what or- 
gan or organs are stteeted ; besides which, sudden changes take place 
from the occurrence of inflammatory action in other pails, so that it 
requires no ordinary share of pathological and practical knowledge 
to act decisively, and yet cautiously. Dr. Culleu gives three general 
indications of cure : — 

1. The removing of the remote causes of the disease. 

2. The evacuation Of the serous fluid already collected in the cel- 
lular texture. 

3. The restoring of the tone of the system, the loss of which may 
be considered in many cases as the proximate cause of the disease. 

The endeavour to fulfil these indications has, I apprehend, bead 
the eattse of much embanassment to practitioners, and increased 
distress to patients. With respect to the first, praciiiioners will, in 
many instances, be found Contending with mere shadows, and wast- 
ing much valuable lima, because the disease may exist after t| H . re- 
moval of its cause, or be even menrab |e, and the patient may ye! he 
■aablsd tO life B SOOSislorahls number of years with tolerable com- 
fort, following his business, provided the attention of the practitionsi 
be directed to certain consequences, the occurrence of which is con- 



868 DROPSY. 

stantly to be dreaded. According to Dr. Bright, "the two great 
sources of casual danger will be found in inflammatory affections, 
more particularly of the serous, sometimes of the mucous membranes, 
and in the effusion of blood or serum into the brain, and the conse- 
quent occurrence of apoplexy. Of the secondary or casual dangers, 
we have illustrative examples in many of the cases which have been 
stated above. Out of the seventeen dissections we have found ten 
or eleven betraying inflammation of the pleura, generally old, but 
sometimes of recent date. We have found three instances in which 
the patients had suffered decided attacks of inflammation in the peri- 
cardium shortly before death, and in two of these cases, we had proof 
of some previous affection of the same kind. In one only were the 
signs of inflammation in the peritoneum well marked. Five out of 
the seventeen had altogether escaped inflammatory affections of the 
serous membranes, and one of these died with inflammation of the 
epiglottis. With regard to the cerebral affections coming on in the 
progress of these diseases, we find, in the cases above related, both 
apoplexy and epilepsy to have occurred; and a very well-marked 
instance of the former was witnessed in a patient in the clinical 
ward in 1825." 

The second indication, "evacuating the serous fluid," may be ful- 
filled in two ways. 1. By evacuating by means of a surgical ope- 
ration, the effused fluid. 2. By exciting the action of the absorbents, 
and producing an increased discharge from some of the excretory 
organs. These are no doubt great objects, if they could be attained ; 
but we must always recollect that the dropsy is a mere symptom or 
consequence of functional or organic disease in some other organ, 
and unless that be cured, much mischief may be done, not only by 
wasting precious time, but by exhibiting medicines which are some- 
times manifestly injurious to the patient. 

Against the third indication — " restoring the tone of the system, 
the loss of which may be considered in many cases as the proximate 
cause of the disease," — I have to enter a strong protest, from the 
injurious consequences which I have seen result from attending to it 
in practice. It accords, however, with Dr. Cnllen's notion, that the 
disease is owing to a general debility, producing a laxity or want of 
tone in the exhalents. 

There is a time that we may stimulate and give tonics with ad- 
vantage, when we have conquered the cause of the disease perhaps 
by debilitating remedies, and when the strength must be supported. 
It will be sufficient for me again to refer to the cases and dissections 
of Dr. Bright, to show the dangers which must often arise from fol- 
lowing such treatment, except under the above restrictions. I have 
met with several medical men in extensive practice, whose invaria- 
ble method of treating dropsy is by giving digitalis and large quan- 
tities of strong gin-toddy, containing an English pint, and sometimes 
even two of the spirit, in the course of twenty-four hours. I would 
implore these individuals to peruse with care the works of Drs. 
Blackall and Bright, who have given us additional guides in the 
treatment of dropsy, by showing the inflammatory diathesis which 
generally prevails, and by directing our attention to the coagulability 



&%** 



[APPENDIX] 883 

No. 66. — Extract of Hyoscyamus and Cicuta. 

R. Extr. hyoscyami, 

Conii, aa 9j. 

Ft. pil. x. One for a dose, to be repeated according to necessity. 

No. 67. — Infusion of Camp/tor and Hops. 

R. Flor. lupulorum, 3j. 

Gum camph. ^ss. 

Aquae bullient. Oj. 

Dose, from a tablespoonful to a wineglassful, every two or three hours. 

No. 68. — Laudanum, Digitalis and Spts. of Nitre. 

R. Tinct. opii, gtt. lxxx. 

Spts. nit ri dnlcis, 3j. 

Aquae deslillatae, 5ij. 

Tinct. digitalis, gtt. xl. 

M. Dose, a teaspoonful every two or three hours. 

No. 69. — Calomel and Opium. 

R. Calomel, 3ij. 

Gum opii, gr. viij. vel x. 

Ft. pil. viij. One to be given every hour or two hours. In culic. 

No. 70. — Ether and Camphor. 

R. Ether, sulphuric. 3j. 

Gum camphorae, oss. 

Dissolve. Dose, from five to ten drops, at short intervals, in a little cold water. 
In sick stomadi accompanying nervous excitement, and in cholera. 

No. 71. — Nux Vomica. 

R. Extr. nuci8 vomicae, ^ss. 

Conserv. rosa>, q. s. 

Ft. pil a xxx. One may be taken two or three times a day. In spasmodic 
diseases. 

No. 72.— Strychnine. 

K. Strychnia pari floats j gr. j. 

( '"Iisitv. rosar. gpfc 

If, Ami divide into twelve pills. One to be taken morning, noon and night. 

No. 73. — Stramonium. 

K. I Air. Pir.imnnii, 

N.ipcmis poriAeat. ^ss. v. 

Ifueilag, gam arab. q. 8. 

Ft. pil. xxx. Done, cue, morning, noon and night 

No. 7 1.— Pills of livlladunna. 

K. Extr. belladonna), gr. vj. 

( ' . . 1 1 - • ■ r v . rose, q. 6. 

Divide into twelve pills. One oi two fof a dose. 

AN riSPASliODICS. 

No, 1~> Music and Camphor. 

H. Mm-, III Opt "J. 

Baeeh. albi, 

< » ■ 1 1 » « arab. ■ ~is8. 

Aqua- deetirl it B, 



84 [APPENDIX.] 

Aquae camphorae, aa^'j* 

M. Dose, a tablespoonful every half hour or hour. 

No. 76. — Castor and Ether. 
R. Tinct. castorei, gss. 

jEther. sulphuric. 3j. 

Aquae destillatse, §iv. 

Tinct. opii, gtt. xl. 

M. Dose, a tablespoonful every hour or two hours. 

No. 77. — Lac Jissafoelida. 

R. Gum assafcet. J)ij. 

Gum arab. 

Sacch. albi, aa gij. 

Aquae cinnam. giv. 

M. A tablespoonful every hour or two hours. 

No. 78. — Jlssafoztida and Musk. 

R. Gum assafcet. 

Moschi opt. aa 9j. 

Mucilag. gum arab. q. s. 

Ft. pil. x. One to be given every hour or two hours. 

No. 79. — Spts. of Hartshorn. 

R. Spts. ammoniae aromat. jss. 

Aquae destillatse, 3iv. 

M. Dose, a tablespoonful every fifteen or twenty minutes, diluted if necessary. 

No. 80. — Valerian and Camphor. 

R. Rad. valerian, contus. 3j. 

Gum camphor. Qij. 

Aquae bullient. Oct. j. 

M. Infuse until cold. Dose, a tablespoonful or more every hour or two 



hours. 



No. 81. — Ether and Laudanum. 



R. JEther. sulphuric. jij. 

Tinct. opii, gtt. lx. 

Aquae menthae, £ij. 

M. Dose, a tablespoonful every ten or fifteen minutes in half a wineglass of 
cold water. 

STIMULANTS. 

No. 82. — Spirits of Turpentine. 
R. Olei terebinth. gtt. cxx. 

Gum arab. 

Sacch. albi, aa gij. 

Aquae destillatse, §iv. 

M. Dose, a tablespoonful every two hours. 

No. 83. — Carbonate of Ammonia. 
R. Carb. ammoniae, gij. 

Sacch. alb. aa 3iss. 

Gum arab. 

Aquae destillatse, §iv. 

M. Dose, same as the former. 

No. 84. — Pills of Cayenne Pepper. 
R. Pulv. capsici, 3ss. 

Mucilag. gum arab. q. s. 

Ft. pil. x. One to be given every hour or two hours. 



[APPENDIX.] 885 

No. 85. — Infusion of Cloves and Ginger. 

R. Caryoph. contus. 

Zinzib. pulv. aa ^ij. 

Aquas bullient. Oct. ss. 

M. Dose, a tablespoonful taken hot and frequently repeated. 

No. 86. — Turpentine and Guaiacum. 

R. Pulv. guaiac. ^ij. 

Terebinth. Venetae, q. s. 

Ft. pil. xij. One to be given every four hours. 

No. 87. — Camphor and Guaiacum. 

R. Tinct. opii camph. 

guaiac. ammoniat. aa 5J. 

M. Dose, a teaspoonful every hour or two hours, in a little water. 

TONICS. 
No. 88. — Columbo, Iron and Ginger. 

R. Pulv. columbo, 

carb. ferri, 

zinzib. aa 3j. 

Ft. pulv. xij. One to be taken thrice a day. 

No. 89. — Gentian and Quassia. 

li. Exlr. gentian, 

quassiae, aa 9sa. 

Ft. pil. x. One to be taken three times a day. 

No. 90. — Sulphate of Quinine. 

R. Sulph. quiniffi, gr. xvj. 

Aquae destillatae, 3 i j . 

M. Dose, a teaspoonful every hour, in the absence of fever. 

No. 91.— I Vine Whey. 

K. Lactie recent Oj. 

Vim M.i.lfirte, ^ij. 

Boil the milk, and then add the wine. 

No. 92.— Subcarb. of Iron and Valerian. 

U. Subearb. ferri, J)ij. 

l'ulv. v.ilcrian, ,^ij. 

ninaiber. 388. 

Ft. pulv. viij. One t" !>'■ taken three times a day. 

No. 93. — ///fusion of ll'ild-cherry Bark. 

K. Curt pruni virg. sj. 

Bern, oaryoph. Jj, 

Aqua porta, Oct. j. 

If, Stand for ;i fern boora. Doee, a arlneglaaaful four times a day. 

No, 94, — Infusion (f Peruvian Hark. 

K . C< ri hoo •■ opt ,^j. 

Aqua: bullient <>j. 

M. and Stand (ill ci. Id. Doee .1 u [neglietfol three or four times a day. 
n . i>. The infnaiona of foaaeia, gentian, Colombo, aerpentaria, <^<'. an 

in the same propOfftionft 

71' 



886 [APPENDIX.] 

No. 95. — Nitrate of Silver. 

R. Nitrat. argenti, gr. j. 

Conserv. rosae, q. s. 

Ft. pil. viij. vel xij. One to be taken morning, noon and night. 

No. 96. — Nitrftte of Silver ivith Belladonna. 

R. Nitrat. argenti, gr. ij. 

Pulv. belladonna?, 9j. 

Extr. glycyrrh. oj. 

Ft. pil. xxxvi. One to be given morning, noon and night. In epilepsy and 
pertussis. 

No. 97. — Aromatic Julep. 

R. Caryopb. 

Nucis moschat. 

Zinzib. aa 3ij. 

Infuse in half a pint of hot water. Dose, a teaspoonful frequently repeated. 
In diarrhaa and cholera morbus. 

ASTRINGENTS. 

No. 9S. 

R. Subcarb. sodae, Bij. 

Cretae ppt. rfj. 
Pulv. gum arab. 

Sacch. albi, aa £ss. 

Aquas destillata?, ^ij. 

01. anisi, gtt. ij. 

M. Dose, a teaspoonful every two, ihree or four hours. Bowel complaints of 

children. 

No. 99. Acetate of Lead, Opium and Calomel. 

R. Acetat. plumbi, 9j. 

Pulv. opii, gr. x. 

Calomel, gr. v. 

Ft. pil. x. One to be given every two, three or four hours. In dysentery. 

No. 100. — Chalk Mixture. 

R. Cretae ppt. 3'j- 
Pulv. gum arab. 

Sacch. albi, aa ^iss. 

Tinct. opii, gtt. xl. 

01. cinnam. git. ij. 

Aquae destillatae, 3iv. 
M. Dose, a tablespoonful every hour or two hours. In diarrhoea. 

No. 101. — Infusion of Logwood. 

R. Ligni haematoxyli, 3J. 

Aquae bullientis, Oj. 

Infuse, and stand till cold. Dose, from a tablespoonful to a wineglassful, 
according to circumstances. 

No. 102. — Sulphate of Zinc and Myrrh. 

R. Sulph. zinci, gr. x. 

Pulv. myrrhae, 5iss. 

Confec. rosae, q. s. 

Ft. pil. xx. Two may be taken morning and evening. 



[APPENDIX] 887 

No. 103.— Tincture of Muriate of Iron. 
R. Tinct. muriat. ferri, ,~j. 

Aquae destillatae, 3 i i j . 

M. Dose, a tablespoonful every three hours. 

No. 104. — Slum Whey. 
R. Lac. bullientis, Oj. 

Pulv. aluminis, gij. 

Boil them until the coagulum separates, and strain. Dose, a wineglassful 
occasionally. 

No. 105. — Yellow Wash. 
R. Corros. muriat. hydrarg. gr. vi. 
Aquas calcis, 3iv. 

M. Used as a wash in venereal ulcers. 

No. 106.— Black Wash. 

R. Calomel, gj. 

Aquae calcis, 5iv. 

M. Used as the preceding. 

INJECTIONS FOR THE URETHRA. 
No. 107.— Acetate of Zinc. 



M. 


R. Acetat. zinci, gr. vj. 
Aquae rosae, t ^iv. 
Injection in gonorrhoea. 




No. 108. — Opiate Injection. 


M. 


R. Gum opii, gr. viij. 
Aquas rosae, 3iv. 
In gonorrhoea. 

No. 109. — Injection of Zinc and Bole 


If. 


R. Sulph. zinci, 9j. 

Boli armenae, 9ij. 

Gum areb. jjiij. 

■ Aquae, 3 viij. 

In gonorrhoea. 




No. 110. — Sulphate of Copper. 




R. Sulph. ni|>ri, <rr. viij. 
Aquae destillatae, ,^ v| ij- 
Tinct. opii, Xiea. 



M. lojeetion for chronic gono r r h oea. 

No. 111. — Styptic Water. 
R. Peril salphat. 

Alum, suljili. U £iu. 

Szij. 

|T6 and fool, tin 11 aild — 

Acid, lutpharie, ,^j. 

'i 1 of the Surgical PhannaeopoBia, and 11 need to check 

asternal basmorrhai 

No. 1 18.— Styptic WattT <>f Copper mat Zinc 
K. Zinci lolphat 

< lopri ■uiphati U srj. 

5viij. 
Dissolve. Used at the preceding. 



888 [APPENDIX ] 

OINTMENTS. 
No. 113. — Kreosote Ointment. 

K. 01. kreosot. gtt. v. 

Cerat. simp. 3j. 

Camphorse gum. oss. 
M. Applied to tetters and ulcerated surfaces. 

No. 114. — Red Precipitate Ointment. 

R. Hydrarg. oxyd. rub. 5j. 

Cerat. simp. ^j. 

Ft. Unguent. In scabies and indolent ulcers. 

No. 115. — Tartar Emetic Ointment. 

K. Tartrat. antimonii, 3j. 

Cerat. simp. §j. 

Mix into an ointment. 

No. 116. — Iodine Ointment. 

R. Iodini, 9j. 

Cerat. simp. 3j. 

Ft. Unguentum. 

No. 117. — Ointment of Hydriodate of Potash. 

H. Hydriodat. potassae, 9j. 

Cerat. simp. ^j. 

Ft. Unguentum. 



INDEX. 



Abirritation, 37. 
Acne, 684. 
Acarus scabiei, 682. 
Albuminuria, 721. 
Amaurosis, 641. 
Amphoric respiration, 417. 
Albumen in dropsies, 462. 
Amenorrha-a, 785. 
Anasarca, 872. 
Anaemia, 42. 459. 513. 
Angina tonsillaris, 195. 

pectoris, 467. 

Aneurism, 503. 

Arteries, ossification of, 502. 

Aortic aneurism, 504. 

Aphtha;, 192. 

Asthenic diseases, 33. 

Ascaris, 227. 

in asthma, 446. 

Asiatic cholera, 281. 

Auscultation, 345. 358. 

Arachnitis, 539. 

Asthma, 439. 

Ascites, 873. 

Atrophy of the heart, 494. 



Biliary calculi, 332. 
lOUnd, 453. 

Blood, diseased conditions of the, 458. 

in plethora, 459. 

in ansem 

in fevei 

in inflammation, iSl. 

in hemorrhage, 462. 

r 163. 

in organic di 

in the nenro • . 168. 

bully, 34. 

Bloody sweat, 

urine, 737. 

B 

Bloe-sku 

Bladder, inflammation of, 718. 

stone "i the 

Brim de 164, 

dc 

Brain, 531, 

inflammation of, LSI. 

Brnner* ■■' ind in rever, 126 

. !:.•■., , -I. 



Bronchitis, 353. 
chronic, 357. 



Cancrum oris, 194. 

Catarrhal ophthalmia, 629. 

Calculus of the kidney, 725. 

Cancer of the uterus, 769. 

Carditis, 480. 

Catarrh, 352. 

Catalepsy, 581. 

Cavernous respiration, 417. 

Cessation of the menses, 804. 

Chemosis,628. 

Chlorosis, 786. 

Chicken-pox, 176. 

Chronic dysentery, 281. 

Chordee, 714. 

Cold stage of fevers, 69. 85. 92. 

Congestion, 86. 

of the lungs, 393. 



Continued fever, 116. 
Cholera morbus, 282. 
Asiatic, 284. 



Congestive fever. 136. 
scarlet fever, 



150. 



M0. 



Chancre, 717. 

Chincou^h, 738. 

Critical days, 67. 

Chorea, 585. 

Constriction of the rectum, 225. 

Consumption, 1 1 1. 

Coma, 527. 

Cow-pox, 171. 

Colic, 314 

Painters', 216. 

Convulsions, 527. 
Ooiica pictonnm, 316. 
Cynanche tonsillaris, 196. 
Croop, 

Crowing di ea ie, VT7. 
Crnsta lactea, I 
Cynanche trachealis, 368. 
• . tobercnlons, 430. 
< 'yanosis, 517. 



D 



Delirium, 538, 

tremen . ,; i I. 

Dentition, im7. 
Diathesis, 1 1. 
Diphtherias, 200. 369. 
D 



INDEX. 



Diarrhoea, 264. 
Dilatation of the heart, 493. 
Dothinenteritis, 257. 
Dropsy, 852. 
Dysentery, 271. 

chronic, 281. 

Dyspnoea, 350. 
Dysmenorrhoea, 792. 



Ear, diseases of the, 644. 
Ecthyma, 682. 
Effusion, pleuritic, 402. 
Egophony, 401. 
Enteritis, 261 
Endocarditis, 482. 500. 
Empyema, 404. 
Emphysema, 441. 

interlobular, 441. 

vesicular, 441. 

Eruptive fever, 143. 
Emprosthotonos, 572. 
Epilepsy, 578. 
Error loci, 16. 
Eryispelas. 652. 
Exsanguinity, 573. 
Excitability, 37. 
Excitation, 37. 
Exanthemata, 143. 
Exudation, 254. 

of blood, 708. 

Eye, diseases of the, 619. 
inflammation of the, 620. 



False croup, 377. 
Fibrine in fever, 460. 

in the phlegmasia 1 , 461 

in organic diseases, 461. 

in the neuroses, 463. 

Fever, doctrines of, 30. 
inflammatory, 122. 

congestive, 125. 

pathology of, 127. 

remittent, 116. 

from inflammation, 120. 

infantile remittent, 112. 

continued, 116. 

causes of, 56. 

typhus, 130. 

synochus, 130. 

physiological doctrines of, 36. 

varieties of, 53. 

intermittent, 68. 

yellow, 99. 

from functional derangement, 117. 

typhoid fever, 134. 

hectic, 141. 

eruptive, 143. 

scarlet, 148. 

Flatulency, 205. 
Fluor albus, 781. 



Gangrene of the mouth, 1! 



Galvanism, mode of using, 582. 
Gastrodynia, 206. 
Gastralgia, 206. 
Gastritis, 259. 
Gallstones, 332. 
Gargouillement, 417. 
Globus hystericus, 583. 
Gleet, 714. 
Gonorrhoea, 713. 
Gout, 817. 839. 
rheumatic, 843. 

H 

Hematuria, 737. 

Haematemesis, 208. 

Haemorrhage from the stomach, 208. 

from the bowels, 210. 



Herpes prseputialis, 748. 
Hectic fever, 141. 
Haemorrhoids, 212. 
Headache, 526. 
Hot stage of fever, 70. 87. 94. 
Haemoptysis, 407. 
Hepatitis, acute, 325. 

chronic, 326. 

Herpes, 693. 
Hepatization, 393. 
Hooping cough, 378. 
Heteromorphism, 418. 
Heart, dilatation of the, 490. 

hypertrophy of the, 485. 

ossification of, 493. 

tuburcles of, 493. 

valvular disease of, 497. 

atrophy of, 494. 

rupture of, 495. 

sounds of the, 451. 

Hyperaemia, 42. 
Hypertrophy of the heart, 484. 
Hydro-pneumothorax, 406. 
Hydropericardium, 477. 
Hydrocephalus, 559. 
chronic, 564. 



Hydrophobia, 575. 
Hysteria, 583. 
Hypochondriasis, 609. 
Hydatids of the uterus, 779. 
Hydrothorax, 873. 



Indigestion, 201. 
Ileus, 220. 
Ileitis, 257. 
Impetigo, 675. 
Incontinence of urine, 735. 
Inflammation, 16. 

causes of, 21. 

terminations of, 25. 

of the tonsils, 195. 

of the throat, 198. 

of the oesophagus, 198. 

of the bowels, 235. 261. 

of the mucous membranes, 

253. 
of the stomach, 259. 



INDEX. 



Inflammation of the spleen, 334. 

of the bronchial tubes, 353. 

of the larynx, 366. 

of the liver, 320. 

of the lungs, 390. 

of the brain, 534. 546. 

— of the spinal marrow, 566. 

of the eye, 620. 

of the conjunctiva, 627. 

of the eyeball, 637. 

of the sclerotica, 637. 

of the iris, 637. 

of the urethra, 713. 

of the bladder, 718. 

of the kidneys, 720. 

of the testes, 761. 

of the uterus, 763. 

Intussusception, 213. 
Intermittent fever, 68. 

treatment of, 91. 

pathology of, 85. 

Intestinal concretions, 225. 

worms, 226. 

Infiltration, tuberculous, 420. 
Irritation, 37, 38. 
Induration of the lungs, 394. 
Insanity, 601. 
Itch, 681. 
Iritis, 637. 

J 
Jaundice, 331. 

K 

Kidney, inflammation of, 720. 



Labiae, diseases of the, 757. 

Laryngitis, 366. 

Leucorrhcea, 781. 

Lepra, 687. 

Lienteria, 264. 

Lichen, (.73. 

Liver, tubercles of the, 330. 

diseases of the, 320. 

acute inflammation of, 324. 

chronic inflammation of, 326. 

abscess of, 827. 

Lungs, diseases of, 345. 
Lockjaw, 571. 
Lumbago, 843. 

M 
Marsh miasmata, 90. 
Mania, 601. 

.M;iin;t-;i-[".ifi, <i I 1. 

Menorrhagia, 

Mcnsps, cessation of the, 804. 
Metallic tinklin 
Melanosis ;::!. 
Melanomia, 486. 
Medullary larcoma, 435. 

. 158. 

in. •ciilation for, 164. 



Melcena, 210. 

Miliaria, 177. 

Miliary fever, 177. 

Monomania, 605. 

Mucous follicles, diseased, 137. 

Mumps, 191. 

N 
Nettle rash, 179. 
Nephritis, 720. 

albuminous, 721. 



Neuralgia, 586. 

— of the heart, 467. 587. 



Nodes, 755. 



(Edema pulmonum, 446. 
Ossification of the heart, 497. 
of the arteries, 502. 



Opisthotonos, 572. 

Opium in cold stage of fevers, 

Ophthalmia, 620. 

catarrhal, 628. 

Egyptian, 628. 

gonorrhoea^ 629. 

purulent, 630. 

infantile, 630. 

pustular, 636. 



Otitis, 644. 
Otorrhoea, 646. 
Ovaria, diseased, 



Pain, 25. 

Pathology of intermiitents, 85. 
Papular diseases, 672. 
Parotitis, 191. 
Palpitation, 465. 
Paralysis, 528. 596. 
Paraplegia, 529. 
Pectoriloquy, 417. 
Peripneumonia nolha, 354. 
lViii]ihiu r us, 625. 

Peritonitis, 236. 

chronic, 249. 



lYrtussis, 378. 

Periodicity, 88. 

Peyer's glands in fever, 138. 257. 

Pericarditis, 474. 

Physiological doctrines, 36. 

Pharyngitis, 198. 

Phlebitis, 506. 

Phlegmasia dolens, 507. 

Phymosis, 748. 

Phthisis pnlmjonalia, 414. 

Pestis, LSI. 

Pityriasis, 88L 

I'M- . 212. 

Plethora, 469.612. 

. 181. 
Pleurisy, mi. 
chronic, 400. 



Meteorism, 136. 



btemorrbagic, 408. 

Pneumonia, 890. 

of children, 398. 



892 



INDEX. 



Podagra, 817. 
Pompholyx, 695. 
Porrigo, 676. 

larvalis, 676. 

Pneumothorax, 406. 
Pulmonary consumption, 414, 

oedema, 446. 

Prolapsus ani, 225. 

uteri, 771. 

Prostate, stone of the, 730. 
Prurigo, 673. 
Psoriasis, 689. 
Pyrosis, 205. 
Purpura, 696. 
Puerperal fever, 237. 
Purulent ophthalmia, 628. 630. 
Pustular ophthalmia, 636. 

diseases, 675. 

Q. 

Quotidian fever, 69. 
Quartan fever, 69. 
Quinine, use of, 97, 98. 

R. 
Ramollissement, 25. 533. 
Red globules in anaemia, 459. 

in haemorrhage, 462. 

in plethora, 452. 

in inflammation, 461. 

Respiratory organs, diseases of, 345. 
Retroversion of the uterus, 773. 
Remittent fever, 116. 
Remittent, infantile, 112. 
Retention of urine, 734. 
Rheumatism, 837. 

chronic, 842. 

Rheumatic gout, 843. 

Roseola, 178. 

Rose-rash, 178. 

Ronchi, 418. 

Rubeola. 158. 

Rupia, 682. 

Rupture of the heart, 495. 

S. 
Scrofula, 844, 
Scabies, 681. 
Scarlet fever, 148. 
Scarlatina, 148. 

Sclerotica, inflammation of the, 637. 
Sciatica, 843. 
Skin, diseases of the, 649. 
Sounds of the heart, 451. 
Small-pox, 164. 

modified, 168. 

Spasmodic cholera, 284. 
Spleen, diseases of the, 334. 

inflammation of the, 334. 

enlargement of the, 385. 

Sthenic diseases, 33. 

Stomatitis, 192. 

Stethoscopic sounds in consumption, ■ 

in aneurism, 498. 

Spinal irritation, 568. 
Squamous diseases, 686. 



Strofulus, 672. 

Stone in the bladder, 729. 

in the urethra, 730. 

Sudamina, 136. 

Sweating stage of fevers, 88. 9-5. 

Sycosis, 685. 

Suppression of urine, 731. 

Syphilis, 747. 

Syphilitic sequellae, 755. 
T. 

Tape worm, 226. 230. 

Tabes mesenterica, 270. 

Tetanus, 571. 

Tertian fever. 69. 

Tenia, 226. 

Testes, inflammation of the, 761. 

Tic douloureux, 587. 

Tracheitis, 368. 

Trismus, 572. 

nascentium, 575. 

Tourniquet in chill, 94. 
| Tubercles of the intestines, 259. 
1 of the liver, 330. 

Typhus fever, 

Typhoid fever, 134. 

Tympanitis, 205. 
I Tubercles of the lungs, 419. 

of the heart, 495. 

of the uterus, 777 



U. 
Urticaria, 179. 
Urethra, inflammation of, 713. 

stone in the, 730. 

Urine, suppression of, 731. 

retention of, 734. 

incontinence of, 735. 

Uterus, inflammation of the, 763. 

cancer of the, 767. 769. 

sarcoma of the, 767. 

prolapsus of the, 771. 

retroversion of the, 773. 

polypus of, 774. 

tubercles of, 775. 

Uvula, inflammation of, 147. 

V. 



Variola, 164. 

Varioloid, 168. 
I Vaccination, 171. 
! Varicella, 176. 

Valvular diseases, 497. 

Vascularity of inflammation, 255. 
j Venereal, 747. 

Vertigo, 526. 

Vesicular diseases, 693. 

Ulceration, 26. 

W. 

Water canker, 194. 

Water-brash, 205. 
I Worms in the intestines, 227. 

in the liver, 332. 

Y. 

Yellow fever, 99. 



THE END. 



i 



DROPSY. 869 

of the urine, as indicating an affection of the kidneys, which affec- 
tion almost always terminates in inflammatory action, to the destruc- 
tion of the organ. 

It is believed by many, and it certainly appears probable, that 
bleeding and the antiphlogistic regimen, within certain limits, act 
upon the absorbent system, by creating greater activity. Blood- 
letting, therefore, as already observed, stands the foremost remedy 1 ; 
but in using it, we must be guided by the age, strength, habits and 
peculiarity of constitution of the individual — the duration of the dis 
ease — and also by the state of the pulse. Should the condition of 
the pulse and other circumstances contra-indicate venesection, local 
bleedings may be had recourse to, either by means of cupping-glasses 
or leeches, and are peculiarly serviceable when applied to the loins 
in cases of diseased liver and kidneys. The propriety of repeating 
the abstraction of blood may be discovered from the state of the 
blood itself, the strength of the pulse and the relief afforded. The 
rash conduct of some practitioners in taking away large quantities 
of blood in all cases, is to be deprecated, because, although it may 
be successful in some instances of dropsy, it will be found to be very 
injurious and even fatal in a majority; and it is greatly to be feared 
that the indiscriminate employment of general bleeding in this dis- 
ease has too frequently led to the adoption of the opposite mode of 
practice already noticed. 

I have seen several cases in which chronic bronchitis existed with 
dropsy, whether as cause or effect, I could not in some instances dis- 
cover; but in all, great and permanent advantage was obtained from 
venesection. 

Purgatives stand next in importance to blood-letting. In all cases 
it is uece^ ip the bowels open; and, in many, we are ob- 

liged to depend on the use of free purgation, when the constitu- 
tion is not sufficiently Btrong to stand the effects of venesection ; con- 
sequently, we find that powerful doses of jalap, gamboge, scammony 
and elaterium, have been highly recommended by different authors. 

I have heard many practitioii-'is declare that they have iicrrr failed 

in earing dropsy by elaterium ; but individuals who make such asser- 
tions, mu8l either have been singularly fortunate In meeting with 
Blight cases only, not produced or accompanied by organic disease, or 
must have been short-sighted or forgetful. In using this class 
medies, practitioners should recollect that violent and long-cofl- 
tinued purging is fully .-is debilitating as venesection, and in point of 
fact, I havi ral individuals die under the action of purga* 

lives, to ail appearance from syncope. 

I had the satisfaction lately of curii ; ascites of Borne 

standing. The disease came on after child-bed, and the abdomen 

very much distended, when the woman was sent from e 

for my advice, After exploring the chest, and ascertaining 

that nil the organs wore sonnd, I had confident expectation of curing 

her without lapping. There was no fever or pain, neither 1 was the 

urine coagulablei She was first put under the acth n of a combirta^ 
Hon of calomel, senilis and digitalis, and kept under it for sevi 
weeks, without much amendment Afterwards, powerful dos< 
7.; 



870 DROPSY. 

elaterium were employed, and with the happiest effects. The 
woman returned home perfectly cured ; I have since heard of her, 
and she continues well. 

In the case of Evans, who recovered, Dr. Bright gave first half-a- 
grain of the extract of elaterium every six hours, and afterwards one 
grain twice a day, and with considerable benefit; but he was sub- 
sequently bled, and took several doses of opium. Dr. Bright seems 
to prefer, however, the saline laxatives, which unite a certain degree 
of diuretic power, and, amongst these, he found the supertartrate of 
potash the most efficacious; indeed, it will be seen, on perusing the 
cases, that in several he trusted almost entirely to this remedy. 

Diuretics have been long used in all cases of dropsical effusion, 
apparently with the simple intention of " pumping the water out of 
the system;" but I am convinced that the active and indiscriminate 
use of these, as well as of drastic purgatives, will become less general 
as our pathological information increases. It appears to me that little 
benefit will be derived in many cases from the use of diuretics, even 
should the effused fluid be absorbed, if the original disease, whether 
it be of the heart and large blood-vessels, the liver or the kidneys, 
remain; and, indeed, in several lingering instances, which I have 
treated by these means, so far successfully as to get rid of the drop- 
sical effusions, the symptoms afterwards became more urgent, and 
the disease more active. 

The principal diuretics employed are squills; foxglove; acetate 
of potash ; supertartrate of potash ; infusion of fresh brooms ; can- 
tharides; oil of turpentine; and balsam of copaiva. Of these, the 
squills and balsam of copaiva I believe to be the best ; Dr. Bright pre- 
fers the former, which he finds to act best in combination with hyo- 
scyamus, or when a grain of opium has been at the same time taken 
once or twice a day; indeed, he says that he considers these two sub- 
stances to form an important part of the treatment, by diminishing 
the irritation of the kidneys, as well as by allaying the general 
disturbance. 

The propriety of tapping is very questionable, unless we are con- 
vinced there is no incurable organic disease ; but I shall return to 
the consideration of this point, when treating of hydrothorax and 
ascites. 

Scarifications are frequently practised in anasarca, and occasionally 
with advantage; but I believe it will, in general, be only temporary; 
and, in many constitutions, inflammation, ulceration of a bad cha- 
racter, and even mortification, sometimes ensue. 

Emetics were formerly in great repute in the treatment of drop- 
sies, owing to the high encomiums passed upon them by the illustri- 
ous Sydenham, who says that antimonial emetics do not seem merely 
to evacuate the stomach, but open some passages from the cavity of 
the abdomen into the intestinal canal. Whatever may be the cause 
I cannot tell, but they seem now to be very much laid aside ; there 
can be no doubt, however, that emetics, either of antimony or copper, 
do promote absorption in a wonderful manner, in induration of the 
testicle ; and although these good effects have been much overrated 
by Sydenham, still, perhaps, they have been abandoned by practition- 
ers of the present day without sufficient examination. 



DROPSY. 871 

Mercury has been often used in dropsy; and there can be no 
doubt that it has been frequently serviceable. It would be a matter, 
however, of the first practical importance, if we could determine 
precisely the cases in which it may be expected to prove beneficial, 
in order to prevent the, loss of much valuable time. We now, by 
means of auscultation and percussion, possess advantages which 
those who lived before us did not enjoy, and almost any ear will be 
able to detect disease of the heart or chronic bronchitis — very fre- 
quent causes of dropsy — in which the action of mercury will cer- 
tainly not be so serviceable as if the liver were diseased. Dr. 
Bright has shown that dropsies frequently depend upon disease of 
the kidneys, in many cases of which mercury may prove decidedly 
injurious, unless preceded or accompanied by general or local bleeding. 
In many instances it will be found serviceable, after bleeding, to 
prescribe a combination of calomel, squills and digitalis, in the form 
of pill, to be repeated in proper doses three or four times a day. But 
Dr. Bright assures us, that the cases which have proved most suc- 
cessful in his own practice, have generally been those in which the 
use of mercury has been rigidly abstained from; and he further 
states, that in some cases he has seen the good effects of other reme- 
dies entirely interrupted by the mercurial action and he has like- 
wise seen several instances in which the cure, when mercurials 
have formed part of the plan, has been protracted to a great length. 
(Page 73.) 

Poultices made of the mole fern applied to the abdomen, have 
been D8ed in several cases of dropsy by Dr. Shorn, in the infirmary 
of Edinburgh, with a view of promoting an increased flow of urine, 
and, it is stated, with remarkably good effects. I have tried this 
remedy in two cases, but without success, although every care was 
taken to procure the plant fresh. 

is and contra-irritation, produced by other means, have been 
occasionally found of great service in dropsies, produced by whatever 
cause. They merely act by translating inflammatory action from 
an internal organ to the skin, ami not, as was formerly ims 
even by Dr. Blackall, by evacuating the dropsical fluid. — I have 
en the best effects from their judicious < rnployment,and they 
appear n> be more particularly useful when applied to the loins after 
topical bleeding in eases of diseased kidney. Formerly, when used 
for the purpose of drawing off the dropsical fluid, they were applied 
to the extremities, and frequently caused sloughing ulcers. 

Great difference of opinion ex-^ts as to the quantity of fluid which 
ought to he allowed to a patient labouring nnder dropsy ; Bome allow 
as much drink as the patient feels inclined to take— 'Others, none at 

all ; I- Hi I believe that a medium plan I- the best to follow. If the 

patient be thirsty, and is interdicted from taking a drink, additional 
suffering and man .1 are the consequence; whereas, 

if he be encouraged '<> drink, he may subsequently experience great 
mm the cvi r-distended state of the stomach, In prac- 
tice, we often take advantage "i the thirst to introduce a sufficient 
quantity of the supertartrate of potash into the. system, I 

::ie who interdict liquids, do BO fol 00 bettei n asou than he- 



872 DROPSY. 

cause it has been stated by authors that dropsical complaints have 
been produced by drinking a large quantity of fluid ! 

I snail now proceed to notice three varieties of dropsy — viz.: an- 
asarca ; hydrothorax ; ascites. 



ANASARCA. 

The term anasarca implies a preternatural collection of serous 
fluid in the cellular texture; and when partial, it is often called 
oedema. This form of dropsy generally comes on slowly, unless it 
succeeds to scarlet fever, when, perhaps, the whole body is observed 
to become suddenly affected ; it also occurs occasionally after taking 
a large drink of cold fluid when the body is much heated. 

In general, the feet are at first observed to be affected in the even- 
ing, and to pit on pressure; the swelling gradually ascends higher, 
and sometimes distends the cellular tissue of the whole body. The 
urine is always scanty and high-coloured; the bowels are generally 
tardy, although now and then they are in a contrary state. The 
general symptoms, as well as the progress and termination of the 
disease, vary according to the organ affected. Sometimes there is 
considerable fever and dry skin ; and the heat of the parts affected is 
sometimes increased, although, in general, it is diminished, and occa- 
sionally mortification takes place. 

Treatment of anasarca. — This must be conducted upon the prin- 
ciples already so fully mentioned. 



HYDROTHORAX. 

Hydrothorax may exist on both sides of the chest, or on one 
only, and may be complicated or not with effusion into the abdo- 
men, and also with general oedema. In the commencement of 
hydrothorax, the symptoms which particularly indicate this form of 
the disease, are, in general, so slight as not to attract much attention, 
and may continue so for a considerable period, although other cir- 
cumstances denoting bad health may exist. The general symptoms 
are those which accompany all forms of dropsical affection. Those 
which are peculiar to hydrothorax are now to be mentioned. At 
first, slight difficulty of breathing is experienced, which is increased, 
during exercise, but more particularly when the body is placed in 
the horizontal posture, and is generally attended by a dry and annoy- 
ing cough. The feet are observed to be swollen towards the even- 
ing ; the extremities become more and more cedematous as the 
disease advances, when the patient frequently complains of palpita- 
tion, increased dyspnoea, which is worse at one time than at another, 
sometimes producing a dread of suffocation, particularly during the 
night. As -the disease goes on to a fatal termination, the patient can 
never lie down, or even recline backwards, or go to sleep in any 
position, without starting up suddenly with increased dyspnoea. The 
surface shows signs of impeded circulation; the cheeks and lips in 



DROPSY. 873 

particular become livid or deadly pale ; and the pulse, if it have 
not hitherto been irregular and intermittent, now becomes so. At 
length the patient dies from suffocation and exhaustion, or becomes 
comatose. The progress of the disease depends much upon the 
organic lesion, and more particularly upon the disease affecting both 
cavities of the pleura, or one only; in which latter case, its progress 
will be much slower, the symptoms much slighter, and the patient 
will be able to repose in the horizontal posture, but on one side 
only." Corvisart has observed that, in the cases where hydrothorax 
exists on one side, oedema also affects the corresponding lower ex- 
tremity. 

Stettioscopic signs. — Before the discovery of auscultation, practi- 
tioners were always in doubt as to the existence of fluid in the chest; 
now, however, by applying the ear to the chest, and by percussion, 
in addition to the other symptoms, the existence of hydrothorax can 
be detected with the greatest certainty. In hydrothorax percussion 
produces a dull sound; and the respiratory murmur is either not 
heard or it is very obscure, except along the vertebral column, 
where it is heard more distinctly. The appearance and shape of the 
chest also afford us additional evidence, but they cannot be depend- 
ed on without having recourse to auscultation and percussion; the 
thorax will be observed to be more rounded than natural, and the 
intercostal spaces increased. 

Treatment of hydrothorax. — The plan of treatment must depend 
upon the cause of the effusion, which may be an organic lesion of 
the heart or lungs, or inflammation of the pleura; and these are to 
be managed upon principles already laid down in the general re- 
marks on dropsical effusions. In cases of threatened suffocation, or 
even when the dyspnoea becomes very severe, it will be proper, in 
many cases, to draw off the water; but we must be careful not to 
hold out the prospect of a cure from such an operation, although wo 
may safely promise considerable temporary relief. We may never- 
tertain some hope, if the effusion be coufined t<» the chest, 
and have been produced by inflammation of the pleura, uncompli- 
cated with disease either of the heart or lungs, and if the patient's 
strength be good. When treating of chronic pleurisy, in the first 

volume of tins work, a successful ease of empyema [a noticed where 

the operation "t paracentuU thoracU was performed by Dr. I'u- 

caim, of Edinburgh ; and there ate many others on record. 



: is, 01 dropsical effusion within the abdomen, may exist 
either alone or complicated with hvdi oihorax and general anasarca. 

The symptoms, as m the other tonus of dropsy, vary according to 

the nature of the cause. On some occasions, the disease is ushered 

In With well-marked symptoms, such at lever, pain m the loins or 

region of the hver, and corresponding disorder of all the functions 
of the body, announced by thirst, loss of appetite, sometimes nausea 
and vomiting, foul tongue, constipated stale of bowels, scanty high- 

73* 



874 DROPSY. 

coloured urine, dry, parched skin, &c. After these symptoms have 
continued for some days, the abdomen will be observed distended ; 
upon percussion it will yield a dull sound, and fluctuation will be 
felt, unless the quantity of the effusion be small, or the intestines 
tympanitic. 

On other occasions, the disease goes on insidiously, the enlarge- 
ment of the abdomen being often, for a considerable time, attributed 
to corpulency; and the other symptoms, such as restless nights and 
loss of appetite, to want of exercise and debility. At length the 
secretion of urine becomes almost suppressed, when symptoms indi- 
cating a cerebral affection sometimes take place and create alarm; 
or, along with scantyhirine, the legs become oedematous, and excite, 
for the first time, a correct notion as to the nature of the patient's 
complaints. 

In all cases of ascites, the most careful examination should be 
made respecting the state of the thorax, as it is much more likely we 
shall be successful in the treatment of a case which is unconnected 
with any organic affection of the contents of the thorax, or with 
effusion into its cavities. We must have recourse, therefore, to aus- 
cultation and percussion, for we cannot judge with any degree of 
certainty from the dyspnoea or the posture of the patient. In ascites 
there may be great dyspnoea from hurried circulation, or from the 
effusion in the abdomen encroaching on the thorax, from which 
causes, also, there may be inability to lie in the horizontal posture. 

In females we may have considerable difficulty in determining 
between ascites and the diseases of the ovaria,in which there is con- 
siderable enlargement; and when treating of diseases of the uterus, 
it was stated how difficult it occasionally is to determine the exist- 
ence of fluid in the abdomen. 

Treatment of ascites. — This must depend, as in other dropsies, 
upon the organ affected, and upon the extent and nature of the dis- 
ease. With respect to tapping, it should be avoided as long as pos- 
sible. We should be guided chiefly by the sufferings produced by 
the distension as well as by the difficulty of breathing. I have been 
frequently on the point of directing the operation to be performed 
when absorption commenced, and afterwards went on rapidly ; and 
on the other hand, I never once had occasion to regret delay. The 
same objection to the operation may be made, as was formerly urged, 
when considering ovarian diseases, that when once we begin to tap, 
we cannot leave off, as the effusion subsequently takes place with 
greater rapidity. The successful case of ascites cured by elaterium, 
noticed at p. 501, was sent to Edinburgh expressly for the operation. 
When the operation is finally determined upon, care should betaken, 
in my humble opinion, to have the patient under the influence of 
diuretics for some days before it is performed. Contra-irritation has 
appeared to me to be more serviceable in ascites than in some other 
forms of dropsy. 



[APPENDIX: 

CONTAINING UPWARDS OF ONE HUNDRED MEDICAL PRESCRIPTIONS.] 



jjy* Many of these prescriptions are referred to by corresponding numbers in the 
text. The classification is one »f nitre cunvtuience. 

CATHARTICS. 

No. 1. — Seidlil: Powders. 

It. Tart, sodaj et potassffi, £ij. 

Superearb. sodas, gij. 

Make a powder, to be dissolved in a gill of cold water. 
R. Acid, tartaric, pulv. gr. xxv. 

To be dissolved in the Bame quantity of water as the preceding powder, the 
two then mixed, and drank in a state of effervescence. 

No. 2. — Calomel and Exlr. of Jalap. 

1£. Calomel, gr. xij. 

El.tr. jalapae, gr. xvj. 

Ft. pil. iv. One to be taken every four hours, until they operate. 

No. 3. — Calomel and Rhubarb. 

R. Calomel, gr. xv. 

Pulv. rhei, gr. xxv. 

Conserv. rosar. a. B< 

Ft. pil. fill. Two to be taken at bed-time, followed by a dose of magnesia 
rning. 

No. i. — .liar. v. Rhubarb, fyc. 

\\. PuIt. aloee, pulv. rln-i Bj <j;r. xij. 

i \. hydrarg. . xij. 

I ispan. <|. s. 

01. rami, gtt. ij. 

Ft. pil. viij. One every three hours until tliuy operate* 

\'>. 5. — Rhubarb and Soaj). 

li. Pulv. rhei, ,~j. 

Bapenii parifitat. ^t. x. 

It. pil, xv. Two or three to be taken el bed-time. 

\ ,. ft.m—Senna and Manna. 

li. I Krji 

M ■ ''''• 5J. 

a. fanicali, Xij. 

M. Inf—ii in n pint of hoi water, and give when eola in divided doeeii — li .. 

powerful cathartic id desired, ad Silt* 



876 [APPENDIX.] 

No. l.—Croton Oil. 

R. 01. Croton. tiglii, gtt. iv. 

Sacch. alb. 

Gum arab. aa gj. 

Aquae menthae, giv. 

M. Dose, a tablespoonful every hour or two hours until it operates. 

No. 8. — Colchicum and Magnesia. 

R. Magnes. ustse, £jss. 
Gum. arab. 

Sacch. alb. aa 9ij. 

Vini colchici, gtt. xl vel lx. 

Aquae menthae, ^iv. 

M. Dose, a tablespoonful every two or three hours, watching its effects. In 

gout and rheumatism. 

No. 9. — Magnesia and Rhubarb. 

R. Magnesias ustae, sjj. 

Pulv. rhei, gr. x. 

zinziber. gr. v. 

M. To be taken in syrup. 

No. 10. — Castor oil, or Oleaginous Mixture. 

R. Olei rieini, gj. 

Pulv. gum. arab. ^iss. 

Sacch. alb. gj. 

Aquae destillatae, giij. 

01. anisi, gtt. ij vel vj. 

To be rubbed up in a mortar. Dose, a tablespoonful every hour until it ope- 
rates. 

No. 11. — Calomel and Gamboge. 

R. Calomel, gr. xvj. 

Gum gambogiae, gr. ij. 

Conserv. rosae, q. s. 
Ft. pil. viij. One to be given every two hours. 

EMETICS. 
No. 12. —Sulphate of Zinc and Ipecacuanha. 

R. Sulph. zinci, £j. 

Aquae destillatae, gjjj. 

Ipecac, pulv. gss. 

_ M. A tablespoonful every fifteen minutes until it operates, ffivino-, at the same 
time, draughts of warm water. 

No. 13. — Solution of Tartarized Antimony. 

R. Antimonii tart. gr. iv. 

Aquae destillatae, gjj. 

M. A tablespoonful to be given every ten or fifteen minutes until emesis 
follows. 

No. 14.— Solutio Vitrolica of Dr. Mosely. 

R. Sulph. zinci, giss. 

Sulph. alum, et potassae, ^ss. 

Aquae ferventis, oct. ss. 

Dissolve and filter. Dose, a tablespoonful for adults, and a teaspoonful for a 
child six months old, every morning on an empty stomach. 



[appendix.] srr 

DIAPHORETICS. 

No. 15. 

R. Antimonii tnrt. gr. j. 

Spts. nitri dulcis, gj. 

Aquae destillauv, ~\v. 

If. Dose, a tablespoonful every hour or two, unless it sickens the stomach. 

No. 16. — Neutral Mixture. 

R. Succi limonis, 3' 88, 

Sub-carb. potassa;, q. s. ad saturandum. 
Saccfi. albi £iss. 

Tart, antimonii, gr. ss. vel gr. j. 
Aquae dostillat;i\ 5iv. 

M. Do6e, a tablespoonful every two hours : in fevers. 

.\ >. 17. — Xitrous Powders. 
R. Nitrat. polassae, 5j. 

Tart, antimonii, gr. ss. vel gr. j. 
Calomel gr. ij. 

Ft. pulv. viij. One to be given every two hours. 

No. IS. — Dover's Powders. 
R. Pulv. opii, 

Ipecac. ai gr. iij. 

Sulpli. potassae, gr. xxiv. 

Ft. pulv. iij. One to be given every three or four hours. 

EXPECTORANTS. 

No. 19. — Prussic Acid. 

R. Acid. Hydrocianici secund. Pharmac. Lond. gtt. xij. 
Syrup, tolutan, 5S3. 

Pulv. (rum. arab. ,~iij. 

Aquae aeatillatse, 5viiss. 

M. Doee, a tablespoonful every three hours. 

►. — Brown Mixture, 
k. Extr. glycyrrh. 

(iiim ar;il>. i;i ,~ij. 

ut. 31V. 
Dissolve and add — 

Spte. niiri diiliis, ,~j. 

\ 11, i antimoni), Jae. 

TiiM-i. .,|iii, <,r|t. \\. 
If. Do D» a ( lblcspoonful every hour, or tWO hoora. 

No, 81.— Tolu Mixture. 

H. (himi arab. ,~j. 

Aqua fervent. net. j. 

Syrup, lolutan. $188. 

Morphls sulph. 

. tart. (?r. j. vel ij. 

M. 1 1 e, a tablea| boor <>r two hours. 

\ >. ~ :. v neka Rooi and Squills. 

K. R ~|. 

pulv. {H, 

oct. j. 

ipoonfal frequently repeat] 



878 [APPENDIX.] 

No. 23. — Copaiva Mixture. 
R. Balsami copaibas, gtt. xl. 

Sacch. albi, zjj. 

Gum. arab. ej. 

Aqua? destillatas, giv. 

M. Dose, a tablespoonful every two hours. 

No. 24. — Peruvian Balsam, fyc. 

R. Balsami Peruv. gss. 

Mel. despumat. gj. 

Rub them together in a mortar, and slowly add — 

Aquas destillatae, g viij. 

M. Dose, a tablespoonful every half hour or hour. In catarrh. 

No. 25.— Uva Ursi and Potash. 
R. Potassae subcarb. 

Pulv. uvae ursi aa. 3j. 

Ft. pulv. viij. One to be given every three hours. 

No. 26. — Gum Ammoniac ivith squills. 

R. Gum ammoniac. ^j. 

Aquas destillatae, giv. 
Dissolve and add — 

Oxymel. scillae, gij. 

Tinct. opii camph. |ss. 
M. Dose, a tablespoonful every two hours. 

DIURETICS. 
No. 27.— Digitalis, Squills, 8,-c.; 

R. Pulv. digitalis, gr. vj. 

Pulv. scillae, gr. xij. 

Calomel, gr. viij. vel xij. 

Ft. pil. xij. One to be given every four or six hours, followed by diuretic 
drinks. 

No. 28.— Squills and Nitre. 

R. Pulv. scillas, gr. vi. 

Nitrat. potassae, ^ss. 

Pulv. zinzib. Qss. 

Ft. pulv. vj.— One to be given every three or four hours, unless they produce 
emesis. 

No. 29.— Oil of Juniper and Nitre. 

R. 01, juniperi, gtt. x. vel xij. 
Sacch. alb. 

Gummi arab. aa gj. 

Aquas destillatae, £\y, 

Spts. nitri dulc. gj. 
M. A tablespoonful every two hours. 

No. 30. — Colchicum and Digitalis. 

R. Vini colchici, gtt. Ix. 

Tinct. digitalis, gtt. xl. 

Aquae destillatae, giv. 

M. Dose, a teaspoonful every two or three hours, watching the effects. 

No. 31. — Turpentine Mixture. 
R. 01. terebinth. gtt. cxx. 

Gum arab. 



[APPENDIX.] 879 

Sacch. alb. aa oiss. 

Aquae destillatae, ^iv. 

01. juniperi, gtt. iv. 
M. A tablespoonful every two hours. 

No. 32. — Copaiva and Cubebs. 

R. Balsami copaib. 

Pulv. cubebae, aa ^iss. 

Gum arab. 

Sacch. albi, aa ^iss. 

Aquae menthae, 5iv. 

M. Dose, a tablespoonful three or four times a day. 

No. 33. — Bicarbonate of Soda and Digitalis. 

R. Bicarb, sodae, o' ss " 

Aquae destillatae, ^iv. 

Tinct. digitalis, gtt. xx. 

M. A tablespoonful to be given every two hours. 

No. 34. — Mixture of Dandelion and Potash. 

R. Extr. taraxaci, 3iss. 

Carb. potassse, zj, 

Aqus3 destillatae, ^iv. 

01. menlhae vel fceniculi, gtt. ij. 

M. Dose, a tablespoonful four times a day. 

ALTERATIVES. 

No. 35. — Iodine and Iodide of Potassium. 

R. Iodid. potassii, gr. vj. 

Iodini, gr. iij. 

Aquae destillatae, ^j. 

M. Dose, from six to twelve drop3 thrice a day, in a little cold water. 

No. .;<;. — /;///,• Pill, Antimonf, cfc. 

R. Sulph. antirnonii praecip. gr. v. 

Mass. ex hydrarg. 

Extr. byoaeyami, U 9j. 

Ft. |>i!. x. One to be given three times a day. In gtutrodytdc^ irri 
t/iach, <J'c. 



No. 37. — Muriatic Acid Mixture. 



K. .Villi murh'.tii". ~j. 

D. eoeti hordfi, l)j. 

r. purificati, ,^j. 

M. DOM| a tablespoonful three or four times a day. In chronic hejialic 



affection*. 



No. 38.— Nitric rfcid Mixture. 



R. Arid, nitri.'i diluti, ,~j. 

A ■ J 1 1 :i : |'i;r.r, ()j. 

K\tr. taraxaci, 3 i j . 

Syrup, tiniib. 5ij. 

M. Dose, ■ tablecpoonfol every two or three, hours. In chronic kepatitit 

So. 39.— Hydriodate qfJron. 

k. [odld. forrii ~i. 

Aqua deaiillatas, .^j. 

M. Dose, six to twelve drops three times a day, in B little cold water. 



880 [APPENDIX.] 

No. 40. — Blue Pill and Rhubarb. 

R. Mass. ex hydrarg. 9ss. 

Pulv. rhei, 9j- 

01. anisi, gtt. v. 

Conserv. rosse, q. s. 

Ft. pil. x. A pill to be taken morning and evening. 

No. 41. — Blue Pill and Gentian. 

R. Mass. ex hydrarg. 9j. 

Extr. gentians, ^ss. 

Conserv. rosse, q. s. 

Ft. pil. x. One to be taken every night at bed-time. 

No. 42. — Blue Pill and Camphor. 

R. Camphora; gum. gr. xvj. 

Mass. ex hydrarg. gr. viij. 

Mucilag. acacia;, q. s. 

Ft. pil. viij. One to be taken morning, noon and night. When a decided ano- 
dyne effect is desired, add from half a grain to a grain of opium to each pill. 

No. 43. — Camphor with Laudanum, fyc. 

R. Aquae camphorae, ^iv. 

Tinct. opii, gtt. xl. vel lx. 

Tinct. lavend. compos. ,~j. vel ^ij. 
M. Give a tablespoonful every two hours. In diarrhoea and dysentery. 

No. 44. — Camphor, Nitric Acid, and Laudanum. 

R. Aquae camphorae, 3iv. 

Acidi nitric i, gtt. iv. 

Tinct. opii, gtt. xl vel lx. 

M. Dose, a tablespoonful every hour or two hours. In diarrhoea and dysen- 



tery. 



No. 45. — Nitro-muriatic Acid Solution. 



R. Acid, nitric. gss. 

muriatic. gtt. xx. 

Aquae destillatae, Jfiv; 

Spts. nitri dulcis, ^ss. 

M. Dose, from twenty to forty drops every three hours, in a wineglass of 
sweetened water. 

No. 46. — Calomel and Opium. 

R. Calomel, gr. ij. 

Gum. opii, gr. iij. 

Ft. pil. viij. — One to be given every three or four hours. 

No. 47. — Non-purgative Saline Mixture in Cholera. 

R. Supercarb. sodae, gij. 

Muriat. sodae, ^iv. 

Chlorat. potassae, gss. 

M. Divide into four powders, one to be given every hour in half a tumbler of 
water. To be continued until reaction takes place, and then given in proportionally 
diminished doses. — Dr. Wakefield. 

EMMENAGOGUES. 

No. 48. — Spurred Rye and Aloes. 

R. Secalis cornut. £j. 

* The nitric acid bath is made by adding an ounce and a half of the acid to a gallon of water. 



[APPENDIX] 881 

Pulv. aloes, gr. viij. vel xij. 

Zinzib. pulv. 9ss. 

Ft. pulv. viij. — One to be taken morning, noon and night. 

No. 49. — Savine and Sulphate of Potash. 
R. Pulv. sabinae, 

Zinzib. pulv. aa 9ij. 

Potassse sulphat. oiss. 

Ft. pil. vi. — One to be taken morning and evening. 

No. 50. — Muriate of Iron ivilh Aloes and Castor. 

R. Tinct. ferri muriat. 
Tinei. aloes compos. 
Tinct. eastorei, aa 3ij. 

M. Give a teaspoonful three times a day, in a wineglassful of infusion of hops. 

No. 51. — Tincture of Hellebore and Myrrh. 

R. Tinct. hellebori nigri, 3ss. 

myrrhs, 3j. 

cantharid. 3j. 

M. Dose, thirty drops morning, noon and night, in a little sweetened water. 

No. 52. — Tincture of Iodine. 

R. Iodini, 9ij. 

SptS. vini rect. ,^j. 

Spts. lavend. compos. JJij. 

M. Dose, from ten to twenty drops thrice a-day, in a little sweetened water. 

No. 53. — Guaiucum, Savine and Copaiba. 

R. Tinct. guaiaci, §j. 

sabinae, 3ij. 

Balsam, copaibae, 38s. 
M. A teaspoonful three limes a day. 

No. 54. — Aloes with Iron, fyc. 

R. Ferri sulphat. 

Potassej -^ulicarb. U 9j. 

Pulv. myrrhs, nj. 

Ft. pil. xxx. Two to be taken every morning and evening. 

ANTHELMINTICS. 

FOR LLMIllllCI. 

\,, 55, — Worm-seed Oil. 

K. oi. chenopodii, 5j- 

Bacch. albi, 

Glim arab. a.i .~ij. 

Aqua deal il lata, jiij. 

Mi To children of two v< .ir> old and opwarda, pvo a teaspoonful four timet a 
day fur three days, ami then administer a briak cathartic. 

\ 55, — Pink-root infusion. 

k. 1; id. 1 

Ar|iia> liulli. nl. Oss. 

Make an Infusion. When sold h may !"• aweetened. To children three yean 

old ami opwards, u'ivc a lahlespoonful three or four timet a <hiv. To adults a 

leeeapful, sratohing In < 

71 



882 [APPENDIX.] 

No. 51.— Electuary of Tin. 

R. Pulv. stanni, §j. 

Syrup, simp. ^iv. 

M. Give this mixture in four doses, on four successive days, and then follow 
it by a brisk cathartic. 

FOR TffiNIA. 

No. 58. — Gamboge and Calomel. 

R. Gambogiae gum. gr. vj. 

Calomel, gr. xvj. 

Pulv. spigeliae, gr. x. 

Ft. pulv. ij. To be taken two successive mornings, and then followed by a 
cathartic of senna and salts. 

No. 59. — Oil of Turpentine. 

R. Olei terebinth. gij. 

Gum arab. 

Sacch. alb. aa ^ij. 

Aquae menthae, giv. 

M. A large tablespoonful to be taken four successive mornings. To be then 
followed by a cathartic. 

FOR ASCARIDES. 

No. 60.—E}iema. 

R. Pulv. aloes, ^ss. 

Aquae fervent. Oss. 

M. To be used as an injection. 

No. 61. — Olive Oil and Camphor Enema. 

R. Aquae camph. 

01. olivarum, aa giij. 

M. Use as an injection. 

NARCOTICS. 
No. 62. — Morphia. 

R. Sulph. morphiae, gr. ij. 

Aquae destillatae, ^ij. 

M. A teaspoonful is equal to sixteen drops of laudanum. 

No. 63. — Opium and Hyoscyamus 

R. Gum opii, gr. iv. 

Extr. hyoscyami, gr. xij. 

Ft. pil. vj. One for a dose. 

No. 64.— Camphor Water and Hoffman's Anodyne. 

R. Aquae camph. giv. 

Liquor, anod. Hoffmani, 3ij. 

M. Dose, a tablespoonful every two hours; diluted if necessary. 

No. 65. — Black Drop and Digitalis. 

R. Tinct. opii acetat. gtt. xl. 

digitalis, gtt. xxx. 

Aquae destillatae, §j. 

M. Dose, a teaspoonful every three or four hours. 



* 





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